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Full text of "Choosing a Medigap policy : ... guide to health insurance for people with Medicare"

Choosing A 
Medigap Policy 




2002 Guide To Health 
Insurance For People 
With Medicare 



For People in the Original 
Medicare Plan 



PUBS 

RA 

412 

.3 

C66 

2002 



This Guide has easy steps to help 
you buy Medicare Supplement 
Insurance. 



CENTERS for MEDICARES MEDICAID SERVICES 



saii 



- 



EH 



*g 



.(Mo Welcome to the 2002 Guide To Health Insurance 
^^ For People With Medicare: Choosing A Medigap 
Policy 

How This Guide Can Help You 

This Guide is about "Medicare Supplement Insurance," also called "Medigap 
Policies." A Medigap policy is a health insurance policy sold by private insurance 
companies to help you pay the medical costs the Original Medicare Plan does not 
cover. Choosing a Medigap policy is a very important decision. 

This Guide provides you with valuable information and helps you understand: 

• What Medigap policies are, 

• How Medigap policies can help you, 

• What to do before you buy a Medigap policy, and 

• How to choose the best policy for you. 

Only you can decide if you need a Medigap policy with the Original Medicare 
Plan. This Guide can help you! 

Remember, there are many things to think about before you decide. There are 
other kinds of health coverage, besides a Medigap policy, that may pay for some 
of your health care costs not covered by Medicare (see page 58). 



"I used this Guide when I was shopping for a Medigap 
policy. The steps to buying a Medigap policy were very 
helpful." 

-Sam 




You don't need a Medigap policy if you are in a Medicare + Choice 

Plan (Medicare managed care plan [like an HMO] or 

Medicare Private Fee-for-Service plan). 



Table of Contents 



Section 1: A Quick Look At Medicare 3-8 

Section 2: Medigap Policy Basics 9-32 

Learning About Medigap Policies 10-13 

Your Medigap Plan Choices 14-17 

Medigap Open Enrollment Period 18-20 

Steps To Buying A Medigap Policy 20-31 

Section 3: More Detailed Medigap Policy Information ..33-56 

Ways Of Pricing Medigap Policies 34-35 

Pre-existing Conditions 36 

Creditable Coverage 37 

Medigap Policies For People Under Age 65 38-40 

Information on Medicare Health Plans and Medigap Policies 40 

Summary of Medigap Protections (Guaranteed Issue Rights) 41-48 

Learning More About Medigap Coverage and Medigap Policies ....49-56 

Section 4: Other Insurance and Ways To Pay 
Health Care Costs 57-66 

Section 5: Coverage Charts 67-75 

Section 6: For More Information .. 77-80 

Important telephone numbers for each state 79-80 

Section 7: Words To Know 

Where words in purple are defined 81-85 

Section 8: Index 

An alphabetical list of what is in this Guide 87-89 

The 2002 Guide To Health Insurance For People With Medicare: Choosing A Medigap 
Policy is not a legal document. The official Medicare program provisions are contained in 
the relevant laws, regulations, and rulings. 

The information in this Guide was correct when it was printed. Changes may occur after 
printing. For the most up-to-date version, look at www.medicare.gov on the Web. Select 
"Publications." Or, call 1-800-MEDICARE (1-800-633-4227). A Customer Service 
Representative can tell you if the information has been updated. TTY users should call 
l_877-486-2048. 



Section 1: 

A Quick Look At 

Medicare 




"We weren't sure what Medicare covered 
until we read over this section." 
-Dan and Mai 



Section 1 : A Quick Look At Medicare 



Medicare has two parts: 

• Part A Hospital Insurance, see page 5. Most people do not have to pay for Part A. 

• Part B Medical Insurance, see pages 5-8. Most people pay monthly for Part B. 



Medigap 
policies only 
help pay 
health care 
costs if you 
are in the 
Original 
Medicare 
Plan. 



Medicare Health Plan Choices 

Depending on where you live, you may be able to get your health care in several 
ways. Medicare offers the following types of Medicare health plans: 



The Original Medicare Plan - The Original Medicare Plan is a "fee-for- 
service" plan. You are charged a fee for each health care service or supply you 
get. This plan, managed by the Federal Government, is available nationwide. 
You will stay in the Original Medicare Plan unless you choose to join a 
Medicare + Choice plan. Many people in the Original Medicare Plan also buy a 
Medigap (Medicare Supplement Insurance) policy to help pay health care costs 
that this plan does not cover. 

Medicare + Choice Plans (pronounced "Medicare plus Choice") - 
Medicare + Choice plans provide care under contract to Medicare. There are 
two types of Medicare + Choice plans. They are available in many parts of the 
country. 



Medicare + Choice Plans include: 

• Medicare managed care plans (like HMOs), and 

• Medicare Private Fee-for-Service plans. 



Words in 
purple are 
defined on 
pages 82-85. 



Important: If you belong to a Medicare + Choice plan, the plan must 
cover at least the same benefits as Medicare Part A and Part B. 
However, your costs may be different, and you may have extra benefits, 
like coverage for prescription drugs or additional days in the hospital. 



It is important to know how you get your Medicare health care. To learn more 
about Medicare, look at your copy of the Medicare & You handbook (CMS Pub. 
No. 10050), which is mailed each fall to people with Medicare. You can order a 
copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. You can also read or print a copy of this handbook at 
www.medicare.gov on the Web. Select "Publications." 



Section 1 : A Quick Look At Medicare 



Medicare Part A 

Medicare Part A (Hospital Insurance) helps pay for: 



For more 
information on 
what Medicare 
Part A covers, 
see the 

coverage chart 
on page 69. 



• Inpatient hospital care, 

• Skilled nursing facility care, 

• Hospice care, and 

• Some home health care. 
How To Get Medicare Part A 

Most people get Medicare Part A automatically when they turn 
age 65. They do not have to pay a monthly payment called a 
premium for Medicare Part A because they or a spouse paid 
Medicare taxes while they were working. This is called 
premium- free Medicare Part A. 

If you (or your spouse) did not pay Medicare taxes while you 
worked, and you are age 65 or older, you still may be able to buy 
Medicare Part A. If you are not sure if you have Medicare Part A, 
look on your red, white, and blue Medicare card. It will show 
"Hospital Part A" on the lower left corner of the card. You can also 
call the Social Security Administration at 1-800-772-1213 or call 
your local Social Security office for more information about 
buying Medicare Part A. If you get benefits from the Railroad 
Retirement Board (RRB), call your local RRB office or 
1-800-808-0772. 



Medicare Part B 



For more 
information 
on what 
Medicare Part 
B covers, see 
the coverage 
charts on 
pages 70-72. 



Medicare Part B (Medical Insurance) helps pay for: 

• Doctors' services, 

• Outpatient hospital care, and 

• Some other medical services that Medicare Part A does not 
cover (like some home health care). 

Medicare Part B helps pay for these covered services and supplies 
when they are medically necessary. 



Section 1: A Quick Look At Medicare 



How To Get Medicare Part B 

You are automatically eligible for Medicare Part B if: 

• You are eligible for premium-free Medicare Part A. 

• You are a United States citizen or permanent resident age 65 
or older. 

Just before you turn 65 years old, you have to decide whether or not to 
enroll in Medicare Part B. You should keep in mind that the cost of 
Medicare Part B will go up 10% for each 12-month period that you 
could have had Medicare Part B but did not sign up for it, except in 
special cases (see pages 7-8, "The Special Enrollment Period For 
Medicare Part B"). 

If you choose to enroll in Medicare Part B, you pay the Medicare 
Part B premium of $54.00 per month in 2002. Rates can change every 
year. For some people, this amount may be higher if they did not 
choose Medicare Part B when they first became eligible at age 65. 

The premium is usually taken out of your monthly Social Security, 
Railroad Retirement, or Civil Service Retirement payment. In these 
cases, you won't get a bill for your premium. If you do not get any of 
these payments, Medicare sends you a bill for your Medicare Part B 
premium every 3 months. If you do not get your bill by the 10th of 
the month, call the Social Security Administration at 1-800-772-1213. 
If you get benefits from the Railroad Retirement Board (RRB), call 
your local RRB office or 1-800-808-0772. 

If you didn't sign up for Medicare Part B when you were first eligible, 
you may sign up during 2 enrollment periods: 

• The General Enrollment Period, see page 7. 

• The Special Enrollment Period, see pages 7-8. 



Section 1: A Quick Look At Medicare 



The General Enrollment Period For Medicare Part B 

This period runs from January 1 through March 3 1 of each 
year. During this time, you can sign up for Medicare Part B at 
your local Social Security office. If you get benefits from the 
Railroad Retirement Board (RRB), call your local RRB office 
or 1-800-808-0772. Your Medicare Part B coverage will start 
on July 1 of the year you sign up. Remember, the cost of 
Medicare Part B will go up 10% for each 12-month period that 
you could have had Medicare Part B but did not take it, except 
in special cases (see below). You will have to pay this extra 
amount as long as you have Medicare Part B. 

The Special Enrollment Period For Medicare Part B 

This period is only available if you waited to enroll in Medicare 
Part B because you or your spouse were working and had 
group health coverage through an employer or union based on 
this current employment. Most people who sign up for 
Medicare Part B during a Special Enrollment Period do not pay 
higher premiums. 

If this applies to you, you can sign up for Medicare Part B 
during the Special Enrollment Period: 

• Any time you are still covered by an employer or union 
group health plan, through your or your spouse's current or 
active employment, or 

• During the 8 months following the month that the employer 
or union group health plan coverage ends, or when the 
employment ends (whichever is first). 

Note: If you are still working and plan to keep your employer's 
group health coverage, you should talk to your benefits 
administrator to help you decide when is the best time to enroll 
in Medicare Part B. When you sign up for Medicare Part B, 
you automatically begin your Medigap open enrollment 
period. Once your Medigap open enrollment period begins, it 
cannot be changed or restarted. See pages 1 8-20 to learn more 
about your Medigap open enrollment period. 



Section 1 : A Quick Look At Medicare 



The Special Enrollment Period For Medicare Part B (continued) 

If you are disabled and working (or you have coverage from a 
working family member), the Medicare Part B Special 
Enrollment Period rules may also apply. 

Remember, most people who sign up for Medicare Part B 
during a Special Enrollment Period do not pay higher 
premiums. However, if you are eligible but do not sign up for 
Medicare Part B during the Special Enrollment Period, you will 
only be able to sign up during the General Enrollment Period 
(see page 7), and the cost of Medicare Part B may go up. 



For more information about signing up for Medicare 
Part A and Part B, call the Social Security Administration 
at 1-800-772-1213. TTY users should call 1-800-325-0778. 



8 



Section 2: 

Medigap Policy 
Basics 




"This section gave me the basic information 
I needed to know to buy a Medigap 
policy." 

-Carol 



Section 2: Medigap Policy Basics 



If you live in 
Massachusetts, 
Minnesota, or 

Wisconsin, different 
types of standardized 
Medigap plans are 
sold in your state. 
For more 
information, see 
pages 73-75. 



What Is A Medigap Policy? 

A Medigap policy is a health insurance policy sold by private insurance 
companies to fill the "gaps" in Original Medicare Plan coverage. 



There are 10 standardized Medigap plans called "A" through "J." The 
front of a Medigap policy must clearly identify it as "Medicare 
Supplement Insurance." Each plan A through J has a different set of 
benefits. Plan A covers only the basic (core) benefits (see page 13). 
These basic benefits are included in all the Plans, A through J. Plan J 
offers the most benefits. 

When you buy a Medigap policy, you pay a premium to the insurance 
company. As long as you pay your premium, a policy bought after 1990 
is automatically renewed each year. This means that your coverage 
continues year after year as long as you pay your premium. This 
premium is different than the Medicare Part B premium. You must also 
pay your monthly Medicare Part B premium. 

However, in some states, insurance companies may refuse to renew 
Medigap policies that you bought before 1990. The law in these states 
did not say these policies had to be automatically renewed each year 
(guaranteed renewable) at the time these policies were sold. 

Medigap policies only help pay health care costs if you have the Origina 
Medicare Plan. You don't need to buy a Medigap policy if you are in a 
Medicare + Choice plan. In fact, it is illegal for anyone to sell you a 
Medigap policy if they know you are in one of these plans. 

If you have Medicaid, it is illegal for an insurance company to sell you a 
Medigap policy, except in certain situations (see page 60). 



Can I Keep Seeing The Same Doctor If I Buy A Medigap 
Policy? 

In most cases, yes. If you are in the Original Medicare Plan and you 
have a Medigap policy, you can go to any doctor, hospital, or other 
health care provider who accepts Medicare. But if you have the type of 
Medigap policy called Medicare SELECT, this is not the case. With 
Medicare SELECT, you must use specific hospitals and, in some cases, 
specific doctors to get your full insurance benefits. 



10 



Section 2: Medigap Policy Basics 



What Is Medicare SELECT? 

Medicare SELECT is a type of Medigap policy available in 
some states. If you buy a Medicare SELECT policy, you are 
buying one of the 10 standardized Medigap plans A through J. 
With a Medicare SELECT policy, you must use specific 
hospitals and, in some cases, specific doctors to get full 
insurance benefits (except in an emergency). For this reason, 
Medicare SELECT policies generally cost less. 

A Medigap Policy Is Not... 

• Coverage you get from your employer or union. 

• A Medicare + Choice plan (like a Medicare managed care 
plan or Medicare Private Fee-for- Service plan). 

• Medicare Part B. 

• Medicaid. 

Why Would I Want A Medigap Policy? 

You may want to buy a Medigap policy because Medicare does 
not pay for all of your health care. There are "gaps" or costs 
that you must pay in the Original Medicare Plan. The chart on 
page 12 gives some examples of these gaps. 

If you are in the Original Medicare Plan, a Medigap policy may 
help you: 

• Lower your out-of-pocket costs. 

• Get more health insurance coverage. 



Words in purple are 
defined on pages 82-85. 



What you pay out-of-pocket in the Original Medicare Plan will 
depend on: 

• Whether your doctor or supplier accepts "assignment" or 
takes Medicare's approved amount as payment in full. 

• How often you need health care. 

• What type of health care you need. 

• Whether you buy a Medigap policy. 

• Which Medigap policy you buy. 

• Whether you have other health insurance. 



11 



Section 2: Medigap Policy Basics 



Gaps In The Original Medicare Plan 

Examples of Gaps in Medicare covered services 
(WhatYouPayin2002) 



A Medigap Policy 
May Help Pay 
These Costs 



Hospital Stays 



$812 for the first 60 days 
$203 per day for days 61-90 
$406 per day for days 91-150 



/ 



Skilled Nursing • Up to $ 1 1 .50 per day for days 2 1 - 1 00 
Facility Stays 



Blood 



Cost of the first 3 pints 



/ 



Medicare 
Part B yearly 
deductible 

Medicare 
PartB 
covered 
services 



$100 per year 



20% of Medicare-approved amount for 
most covered services 
50% of the Medicare-approved amount for 
outpatient mental health treatment 
Copayment for outpatient hospital services 



/ 



/ 



Note: Some Medigap policies also cover other extra benefits that are not 
covered by Medicare, like: 

• Routine yearly check-ups. 

• At-home recovery. 

• Medicare Part B excess charges (the difference between your 
doctor's charge and Medicare's approved amount). The excess 
charge only applies if your doctor doesn't accept assignment. 

• And more (see page 14). 



You don't need a Medigap policy if you are in a Medicare + Choice plan. 



12 



Section 2: Medigap Policy Basics 



What Medigap Policies Cover 

Each standardized Medigap policy must cover basic (core) benefits 
(see below). Medigap policies pay most, if not all, of the Original 
Medicare Plan coinsurance and outpatient copayment amounts. These 
policies may also cover the Original Medicare Plan deductibles. 
Some of the policies cover extra benefits to help pay for more of 
those things that Medicare doesn't cover, like prescription drugs. If 
you live in Massachusetts, Minnesota, or Wisconsin, see pages 73-75. 

What Medigap Policies Don't Cover 

• Long-term care 

• Vision or dental care 

• Hearing aids 

• Private-duty nursing 

• Unlimited prescription drugs 

Who Can Buy A Medigap Policy? 

To buy a Medigap policy, you generally must have Medicare Part A 
and Part B. If you are under age 65 and you are disabled or have 
End-Stage Renal Disease (ESRD), you may not be able to buy a 
Medigap policy until you turn 65. 

See pages 38-40 if you want to know more about Medigap policies 
for people under age 65. 



Remember, Medigap policies only work with the Original 
Medicare Plan. 



If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, see 
pages 73-75. 



Medigap Plans A through J Basic (Core) Benefits 

All Medigap plans must cover these basic (core) benefits (see page 14): 

• The Medicare Part A coinsurance amount. 

• The cost of 365 extra days of hospital care during your lifetime after 
Medicare coverage ends. 

• The Medicare Part B coinsurance or copayment amount. 

• The first 3 pints of blood each year. 

13 



Section 2: Medigap Policy Basics 



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Section 2: Medigap Policy Basics 



How Much Do Medigap Policies Cost? 

This Guide can't include actual costs for Medigap policies. As 
you shop for a Medigap policy, you will need to call insurance 
companies that sell Medigap policies in your state and ask 
about prices. 

The cost for Medigap policies will be different depending on: 

• Your age, 

• Where you live, and 

• The insurance company. 

There can be big differences in the premiums that 
insurance companies charge for exactly the same coverage. 

When you compare premiums, be sure you are comparing the 
same Medigap policies. 

Insurance companies have 3 different ways of pricing policies 
based on your age. In general, no-age-rated (also called 
community-rated) policies are the least expensive over your 
lifetime. For more details, see pages 34-35. 

Other Factors That May Affect Your Cost: 

• Whether you are male or female. Some companies offer 
discounts for females. 

• Whether you smoke or not. Some companies offer 
discounts for non-smokers. 

• Whether you are married or not. Some companies offer 
discounts for married couples. 

• Medical Underwriting. This is a process that a company 
uses to review your health and medical history, and decide 
whether to accept your application for insurance. 

With medical underwriting, you usually must answer medical 
questions on an application. You need to fill out this 
application carefully. Some companies may want to review 
your medical record before they sell you a policy. The 
company may use this information to add a waiting period 



15 



Section 2: Medigap Policy Basics 



How Much Do Medigap Policies Cost? (continued) 

Other Factors That May Affect Your Cost: (continued) 

• Medical Underwriting, (continued) 

for pre-existing conditions if your state law allows. The 
company may also use this information to decide how much 
to charge you for a Medigap policy. Insurance companies 
may "medically underwrite" any Medigap policy at times 
other than your Medigap open enrollment period (see page 
1 8) or when you have the right to buy a Medigap policy (see 
page 41). 

• Whether you buy a High Deductible Option Policy. 

Insurance companies may offer a "high deductible option" 
on Medigap Plans F and J (see chart on page 14). If you 
choose this option, you must pay a $ 1 ,620 deductible for the 
year 2002 before the plan pays anything. This amount can 
go up each year. 



High deductible option policies often cost less, but if you 
get sick, your out-of-pocket costs will be higher and you 
may not be able to change plans. 

In addition to the $1,620 (in 2002) deductible that you must 
pay for the high deductible option on Plans F and J, you 
must also pay deductibles for: 

• Prescription drugs ($250 per year for Plan J), and 

• Foreign travel emergency ($250 per year for Plans F and J). 



Words in purple are 
defined on pages 82-85. 



16 



Section 2: Medigap Policy Basics 



How Much Do Medigap Policies Cost? (continued) 

Other Factors That May Affect Your Cost: (continued) 

• Whether you buy a Medicare SELECT Policy. 

Medicare SELECT is a type of Medigap policy available in 
some states. If you buy a Medicare SELECT policy, you 
must use specific hospitals and, in some cases, specific 
doctors to get full insurance benefits (except in an 
emergency). For this reason, Medicare SELECT policies 
generally cost less. 

If you don't use a Medicare SELECT hospital or doctor for 
non-emergency services, you will have to pay what 
Medicare doesn't pay. Medicare will pay its share of 
approved charges no matter what hospital or doctor you 
choose. 



17 



Section 2: Medigap Policy Basics 



When Is The Best Time To Buy A Medigap Policy? 

The best time to buy a Medigap policy is during your Medigap 
open enrollment period. 

Your Medigap open enrollment period lasts for 6 months. It starts 
on the first day of the month in which you are both: 

• Age 65 or older, and 

• Enrolled in Medicare Part B. 

Once the 6-month Medigap open enrollment period starts, it 
cannot be changed. 

During this period, an insurance company cannot: 

• Deny you insurance coverage, 

• Place conditions on a policy (like making you wait for 
coverage to start), or 

• Charge you more for a policy because of past or 
present health problems. 



Words in purple are 
defined on pages 82-85. 



18 



If you buy a Medigap policy during your Medigap open 
enrollment period, the insurance company must shorten the 
waiting period for pre-existing conditions by the amount of 
previous health coverage you have. This is called "creditable 
coverage." 

See page 36 for more information about pre-existing 
conditions. If you want to know more about creditable 
coverage, see page 37. If you are disabled or have End-Stage 
Renal Disease (ESRD), see pages 38-40. 

You can tell if you are in your Medigap open enrollment period 
by looking at your red, white, and blue Medicare card. This 
card shows the dates that your Medicare Part A and Part B 
coverage started. If you are age 65 or older, add 6 months to 
the date that your Medicare Part B coverage starts to figure out 
if you are in your Medigap open enrollment period. If that date 
is in the future, you are still in your Medigap open enrollment 
period. If that date is in the past, you have missed your 
Medigap open enrollment period (see example on page 19). 



Section 2: Medigap Policy Basics 



When Is The Best Time To Buy A Medigap Policy? 
(continued) 



Medigap Open Enrollment Period Example: 

It is October 1, 2002, and Mr. Rodriguez wants to buy a 
Medigap policy. He needs to know if he is in his open 
enrollment period. He looks at his Medicare card. His 
Medicare Part B coverage started August 1, 2002. To figure 
out if he is in his open enrollment period, he must add 6 
months to his Medicare Part B start date and see if it is 
before or after the current date. 

Mr. Rodriguez: August 1, 2002 + 6 months = January 31, 2003 

Since it is October 1, 2002, he is still in his open enrollment 
period. Mr. Rodriguez has until January 31, 2003, to buy any 
Medigap policy during his Medigap open enrollment period. 



Should I Enroll In Medicare Part B And Start My 
Medigap Open Enrollment Period If I Am Age 65 Or 
Older And Still Working? 

You may want to wait to enroll in Medicare Part B if you or 
your spouse are working and have group health coverage 
through an employer or union based on your or your spouse's 
current or active employment. Your Medigap open 
enrollment period won't start until after you sign up for 
Medicare Part B. Remember, once you're age 65 or older and 
enrolled in Medicare Part B, the Medigap open enrollment 
period starts and cannot be changed. 



19 



Section 2: Medigap Policy Basics 



What If I Enrolled In Medicare Part B and Did Not Use 
My Medigap Open Enrollment Period To Buy A 
Medigap Policy? 

If you apply for a Medigap policy after your open enrollment 
period has ended, the Medigap insurance company is allowed 
to use medical underwriting to decide whether to accept your 
application, and how much to charge you for the policy. If you 
are in good health, the insurance company is likely to accept 
your application, but there is no guarantee that you will get the 
policy 

Steps To Buying A Medigap Policy 

Buying a Medigap policy is an important decision. Only you 
can decide if a Medigap policy is the right kind of health 
insurance coverage for you. If you decide to buy a Medigap 
policy, shop carefully. Look for a policy that you can afford 
and that gives you the coverage you need most. As you shop 
for a Medigap policy, keep in mind that different insurance 
companies may charge different amounts for the same type of 
Medigap policy. 

The steps to buy a Medigap policy are: 

Step 1 : Look at how much you're spending on health care each 
year (see pages 21-22). 

Step 2: Think about your future health care needs, review the 
Medigap plans, and decide which benefits you want or 
need (see pages 23-26). 

Step 3: Find out which insurance companies sell Medigap 
policies in your state (see page 27). 

Step 4: Call the insurance companies and compare costs (see 
pages 28-29). 

Step 5: Choose the best Medigap policy for you (see page 30). 

Step 6: Buy the Medigap policy (see page 31). 



20 



Section 2: Medigap Policy Basics 



Step 1. Look at how much you're spending on health 
care each year. 

Use the worksheet on page 22 to write down your yearly 
expenses for health care. If you don't know your yearly 
expenses, use the worksheet to check off the health care costs 
and services you paid for (called out-of-pocket costs) (see 
"How To Use The Worksheet" below). This will help you 
decide which Medigap policy benefits you need. It will also 
help you when you begin to shop for the Medigap policy that's 
right for you. 

Important: You should also think about your future health care 
needs. As you get older, your health care costs may increase. 




How To Use The Worksheet 

• Column 1 lists types of health care services that you may 
have paid for last year. You can also add other health care 
services that you paid last year (or previous years) that you 
may want to think about when choosing a Medigap policy. 
Write those services in the row marked "Other." 



Words in purple are 
defined on pages 82-85. 



For Column 2: 

• Write down the cost for the services you used and paid for 
last year, or place a check mark for health care costs you 
paid for. 

• Look at the amounts in Column 2. Rows with the largest 
dollar or cost amounts are most likely the benefits you may 
need in a Medigap policy right now. Remember, you should 
also think about your future health care needs (see pages 24- 
25). For example: 

Let's say you did not have a hospital stay last year, so you 
did not have to pay a Medicare Part A hospital deductible. 
Next year, or sometime in the future, you may end up in a 
hospital. If you did not buy a Medigap policy that covers the 
Medicare Part A hospital deductible, you will have to pay 
this cost for each benefit period ($812 in 2002). 



21 



Section 2: Medigap Policy Basics 




Yearly Health Care Cost Worksheet 



Column 1 


Column 2 


Health Care Services 


How Much Did I Pay Last 
Year? (Write down amount or j 
check if you paid last year.) 


Skilled Nursing Coinsurance up to $101.50 
a day (in 2002) for days 21-100 in a skilled 
nursing facility. 


$ 


Medicare Part A Hospital Deductible ($812 
[in 2002] for days 1-60 of a hospital stay). 


$ 


Medicare Part B Yearly Deductible ($100 
in 2002). 


$ 


Medicare Part B Excess Charge 

(The difference between your doctor's actual 

charge and Medicare's approved amount.) 


$ 


Foreign Travel Emergency 

(Any emergency care you received outside 

of the United States.) 


$ 


At-Home Recovery 
(Help you received at home with daily 
activities like bathing and dressing when 
you are already getting Medicare-covered 
home health visits.) 


$ 


Prescription Drugs 


$ 


Preventive Care 

(Such as routine yearly check-ups, serum 
cholesterol screening, hearing tests, 
diabetes screening, and thyroid function 

tests.) 


$ 


Other: 


$ 



22 



Section 2: Medigap Policy Basics 




Step 2. Think about your future health care needs, review 
the Medigap plans, and decide which benefits you 
want or need. 



If you decide to buy a Medigap policy, make sure it covers the benefits 
you want or need. You should also think about benefits you may need 
in the future. Think about your medical history, your family medical 
history, and health risks when thinking about future health care costs. 

On the next two pages you'll find a worksheet you can use. If you 
complete this worksheet, you should have a good idea of the types of 
benefits you want to look for in a Medigap policy. The worksheet 
includes a list of extra benefits that different Medigap policies cover. 
Next to each benefit is a reason why you might want or need that benefit. 



1. Put a check in the column "Do I want or need these extra benefits?" 
next to the extra benefits you need or want. 

2. Turn to the chart on page 14 that lists all the Medigap plans and their 
benefits. On that chart, circle the benefits you checked on the 
worksheet. 

3. Look at the benefits you circled on page 14, and find the plan that has 
most, if not all, of the benefits you need or want. Remember, all of the 
plans cover the basic benefits (see below). The plan you choose may 
not match your needs exactly. You may have to give up or buy extra 
benefits to get a plan that is close to what you want. 

The basic (core) benefits included in all Medigap policies are: 

• The Medicare Part A coinsurance amount for days 61-90 ($203 per day in 
2002), and days 91-150 ($406 per day in 2002) of a hospital stay. 

• 100% of the cost for up to 365 more days of a hospital stay during your 
lifetime after you use up all Medicare hospital benefits. 



• The coinsurance or copayment amount for Medicare Part B services 
after you meet the $100 yearly deductible (in 2002). 

• The first 3 pints of blood or equal amounts of packed red blood cells 
per calendar year, unless this blood is replaced. 

23 



Section 2: Medigap Policy Basics 



Medigap policy extra benefits 


Reasons you might want or 
need these extra benefits 


Do 1 want or need 
these extra benefits' 


Skilled Nursing Coinsurance 

Up to $101.50 a day (in 2002) for 
days 21-100 in a skilled nursing 
facility. 


You may need this benefit if you have 
to go to a skilled nursing facility 
(SNF) after a hospital stay and stay in 
the SNF longer than 20 days. 




Medicare Part A Hospital 
Deductible 

$812 for days 1-60 of a hospital stay 
(in 2002). This amount can change 
every year. 


You may need this benefit if you have 
to stay in the hospital. You have to pay 
the Medicare Part A deductible each 
benefit period 




Medicare Part B Yearly Deductible 

$100 per year in 2002. 


You may want to think about this 
benefit if you have Medicare Part B. 
Each year you must pay the Medicare 
Part B deductible before Medicare 
starts to pay its share. If you have this 
benefit, the Medigap policy would 
pay this amount each year. 




Medicare Part B Excess Charge 

The difference between your doctor's 
actual charge and Medicare's 
approved amount, if your doctor 
does not accept assignment. 
Plans F, I, and J pay all of the excess 
charges. Plan G pays 80% of the 
excess charges. 


You may want to think about this 
benefit if your doctors don't accept 
assignment. You may also want this 
benefit if you have to stay in the 
hospital and can't control whether the 
doctors you see accept assignment. 
Under federal law, doctors who don't 
take Medicare's approved amount as 
payment in full (accept "assignment"), 
may charge up to 15% more than the 
approved amount. 




Foreign Travel Emergency 

80% of the cost of emergency care 
during the first 60 days of each trip 
(after the $250 deductible). 

Up to $50,000 in your lifetime. 


You may want to think about this 
benefit if you travel outside the 
United States. This benefit could save 
you money for emergency care. 





24 





Section 2: Medigap Policy Basics 


Medigap policy extra benefits 


Reasons you might want or 
need these extra benefits 


Do 1 want or need these 
extra benefits? 


At-Home Recovery 

The cost of at-home help with 
daily activities like bathing and 
dressing if you are already 
getting Medicare-covered home 
lealth visits. 

Up to 8 weeks of at-home help 
after skilled nursing care is no 
onger needed. 

Will pay up to $40 each visit 
and $1,600 each year. 


This benefit covers additional 
care at home if you are already 
getting Medicare-covered home 
health services. This benefit 
may add to the cost of the 
policy, and you may not need it. 




Prescription Drugs 

50% of the drug costs that 
Medicare doesn't cover (after 
you pay a $250 per year 
deductible). 

Up to $1,250 each year under 
Plans H and I (Basic drug 
benefit). 

Up to $3,000 each year under 
Plan J (Extended drug benefit). 


You may want to think about 
this benefit if you have high 
prescription drug costs. It covers 
half your drug costs after the 
yearly deductible up to a 
maximum amount. Therefore, to 
get the full benefit under Plans H 
and I, you should have at least 
$2,750 in drug costs in a year (you 
pay $1,250 plus $250; plan pays 
$1,250). To get the full benefit 
under Plan J, you should have at 
least $6,250 in drug costs in a year 
(you pay $3,000 plus $250; plan 
pays $3,000). 




Preventive Care 

(such as routine yearly check- 
ups, serum cholesterol 
screening, hearing tests, 
diabetes screening, and thyroid 
function tests). 

Up to $120 each year. 


This benefit helps pay for 
routine yearly check-ups and 
tests that may be important to 
you to keep you healthy. 





25 



Section 2: Medigap Policy Basics 



Step 2. Think about your future health care needs, 
review the Medigap plans, and decide which 
benefits you want or need, (continued) 



If you decide to buy a Medigap policy, make sure it covers the 
benefits you want or need. If you need help to decide which 
Medigap policy is best for you, call your State Health 
Insurance Assistance Program (see pages 79-80). 



Note: If you live in Massachusetts, Minnesota, or Wisconsin, 
see pages 73-75 for more information about the Medigap 
plans that are sold in your state. These states have different 
types of standardized Medigap plans. 



Words in purple are 
defined on pages 82-85. 



26 



Section 2: Medigap Policy Basics 





Step 3. Find out which insurance companies sell 
Medigap policies in your state. 

To find out which insurance companies sell Medigap policies 
in your state, you can: 



• Call your State Health Insurance Assistance Program 
(see pages 79-80). Ask if they have a Medigap rate 
comparison shopping guide for your state. These types 
of guides usually list the insurance companies that sell 
Medigap policies in your state and compare the costs of 
policies for each company. 

• Call your State Insurance Department (see pages 79-80). 

• Look at www.medicare.gov on the Web. Select 
"Medicare Personal Plan Finder" (see page 40). 

This website will help you find information on all 
your health plan options, including Medigap policies 
in your area. You can also get information on: 

/ Some companies that sell Medigap policies in your 
state. 

«/" What the policies must cover. 

/ How insurance companies decide what to charge 
you for a Medigap policy premium. 

If you don't have a computer, your local library or 
senior center may be able to help you look at this 
information. 

• Call 1-800-MEDICARE (1-800-633-4227). For English, 
press (1) or for Spanish, press (2). Select option "0." A 
Customer Service Representative will help you get 
information on all your health plan options, including 
Medigap policies in your area. You will get your 
Medicare Personal Plan Finder results in the mail within 
three weeks. TTY users should call 1-877-486-2048. 

You should plan to call more than one insurance company 
that sells Medigap policies in your state. Make sure the ones 
you choose to call are honest and reliable (see page 56). 



27 



Section 2: Medigap Policy Basics 




Step 4. Call the insurance companies and compare costs. 

Call different insurance companies and ask questions. Friends and relatives 
can tell you about their policies, but their policies may not fit your needs. 
Shop around for the best Medigap policy for you at a price you can afford. 

Ask each insurance company the following questions: 

• Is this insurance company licensed in this state? (The 
answer should be yes.) 

• Which Medigap policies do you sell? (Make sure they 
sell the plan you want.) 

• What is the cost of the Medigap policy I am interested in? 

• How is this price decided? 

■ What is the type of pricing used by the insurance company? 

■ Does it make a difference if I am male or female? 

■ Does it make a difference if I smoke or don't smoke? 

■ Does it make a difference if I am married or single? 

• Are there any additional ("innovative") benefits or discounts 
included in this policy? 

If you are not in your Medigap open enrollment period or in a 
situation where you have a guaranteed issue right to buy a 
Medigap policy (see pages 41-48), ask: 

• Will you accept my application? 

• Do you review my health records or application to decide 
how much to charge me for a Medigap policy? 

• Will I have to wait for my pre-existing conditions to be 
covered if I already have a health problem? 



Use the comparison worksheet on page 29 to write down 
the insurance company answers. This will help you 
compare costs and benefits you are considering. 



28 



Section 2: Medigap Policy Basics 



Medigap Policy Comparison Worksheet 

Use this worksheet to compare costs and benefits you are considering. Make sure you get the 
agents' and the companies' names, addresses, and telephone numbers. 



Ask each insurance 
company: 



[s this insurance company licensed in this 
state? (The answer should be yes.) 



Insurance 
Company 1 



Insurance 
Company 2: 



Insurance 
Company 3: 



Which Medigap policies do you sell? 
(Make sure they sell the plan you want.) 



What is the cost of the Medigap policy I 
am interested in? 



How is the price decided? 

• What is the type of pricing used by the 
insurance company? 

• Does it make a difference if I am male 
or female? 

• Does it make a difference if I smoke or 
don't smoke? 

• Does it make a difference if I am 
married or single? 



Are there any additional ("innovative") 
benefits or discounts included in this policy? 



If you are not in your Medigap open 
enrollment period or in a situation where 
you have guaranteed issue right, ask: 

• Will you accept my application? 

• Do you review my health records or 
application to decide how much to 
charge me for a Medigap policy? 

• Will I have to wait for my pre-existing 
conditions to be covered if I already 
have a health problem? 



29 



Section 2: Medigap Policy Basics 



Step 5. Choose the best Medigap policy for you. 




After you call the insurance companies and compare their 
costs, choose the Medigap policy that is best for you. 

But, before you make your final choice, make sure: 

□ You carefully review the Medigap policy benefits, 
n You can afford the cost of the policy. 

□ The policy covers the benefits you need and want. 

You feel good about and trust the insurance company 
and/or the insurance agent. 

□ You talk with someone you trust, like a family 
member, friend, doctor, or insurance agent about 
your choice. 

Once you've checked the items above, you are now 
ready to move on to Step 6. 



30 



Section 2: Medigap Policy Basics 




Step 6. Buy the Medigap policy. 

Once you have decided on the insurance company and the 
Medigap policy you want, you can buy your policy. The 
insurance company must give you a clearly worded summary of 
your Medigap policy. Read it carefully If you don't understand 
it, ask questions. When you buy your Medigap policy: 

□ Fill out your application carefully and completely. Answer 
all of the medical questions. If the insurance agent fills 
out the application, review it to make sure it's correct. 

] Don't buy more than one Medigap policy. If you already 
have a Medigap policy, it is illegal for an insurance 
company to sell you a second policy unless you put in 
writing that you are going to cancel the first Medigap 
policy. However, do not cancel your first Medigap policy 
until the second one is in place, and you decide to keep the 
second Medigap policy You have 30 days to decide if you 
want to keep the new policy. This is called your "free look" 
period. 

□ Do not pay cash. Pay for your policy by check, money 
order, or bank draft. Make it payable to the insurance 
company, not the agent. 

□ Ask for your Medigap policy to become effective when you 
want coverage to start, or when your previous policy's 
coverage ends. If, for any reason, the insurance company 
will not give you the start date you want, call your State 
Insurance Department (see pages 79-80). 

| Get a receipt with the insurance company's name, address, 
and telephone number for your records. 

Q Make sure you get your policy within 30 days. If you 
don't get your policy in 30 days, call your insurance 
company. If you don't get your policy in 60 days, call your 
State Insurance Department (see pages 79-80). 



31 



NOTES 



"I keep this book on my shelf so I know 
where to find it if I have a question." 

-Joseph 




32 



Section 3: 

More Detailed Medigap 

Policy Information 




"Before we bought a Medigap policy, we used 
this section to learn more about Medigap 
policies." 

-Tom and Fran 



33 



Section 3: More Detailed Medigap Policy Information 



The Cost Of Medigap Policies: Ways Of Pricing Policies 

Insurance companies have 3 different ways of pricing Medigap 
policies based on your age: 

1 . No-age-rated (also called community-rated) 

2. Issue-age-rated 

3. Attained-age-rated 

1. No-age-rated (also called community-rated) policies 

These policies charge everyone the same rate no matter how old 
they are. 



Example*: Mrs. Smith pays the same monthly premium at each age 
plus any premium increases the company may charge because of 
inflation. 



* Remember, 
all monthly 
premiums 
may change 
and go up 
each year 
because of 
inflation and 
rising health 
care costs. 



Monthly Premium at Age 65 
Monthly Premium at Age 75 
Monthly Premium at Age 85 



$155 

$155 
$155 



2. Issue-age-rated policies 

The monthly premium for these policies is based on your age 
when you first buy the policy. The cost does not automatically go 
up as you get older. Your premium will be the same as anyone 
buying a policy for the first time at your age. 

Example* : Mrs. Smith pays the same monthly premium 
depending on how old she is when she buys the policy. 
She also pays any additional premium increase the company may 
charge because of inflation. 

Buy Policy at Age 65 



Monthly Premium at Age 65 
Monthly Premium at Age 75 
Monthly Premium at Age 85 



$130 
$130 
$130 



Buy Policy at Age 75 

Monthly Premium at Age 65 

Monthly Premium at Age 75 $ 1 65 

Monthly Premium at Age 85 $ 1 65 



34 



Section 3: More Detailed Medigap Policy Information 



The Cost Of Medigap Policies: Ways Of Pricing 
Policies (continued) 



* Remember, 
all monthly 
premiums 
may change 
and go up 
each year 
because of 
inflation and 
rising health 
care costs. 



2. Issue-age-rated policies (continued) 

Buy Policy at Age 85 

Monthly Premium at Age 65 
Monthly Premium at Age 75 
Monthly Premium at Age 85 $ 1 95 

3. Attained-age-rated policies 

The monthly premiums for these policies are based on your age 
each year. These policies generally cost less at age 65, but their 
costs go up automatically as you get older. 

Example*: Mrs. Smith buys the policy at age 65, and pays 
higher monthly premiums as she gets older. She also pays any 
additional premium increases the company may charge because 
of inflation. 



Monthly Premium at Age 65 
Monthly Premium at Age 75 
Monthly Premium at Age 85 



$115 
$160 
$200 



Caution: In general, attained-age-rated policies are cheaper 
than issue-age-rated policies the first few years you own the 
policy. However, rate increases for attained-age-rated policies 
are usually larger than rate increases for issue-age-rated 
policies. After a period of time, the premiums for an attained- 
age-rated policy will be higher than what the premiums would 
have been if you had an issue-age-rated policy. 



35 



Section 3: More Detailed Medigap Policy Information 



Medigap Coverage Of Pre-existing Conditions 

What Is A Pre-existing Condition? 



A pre-existing condition is a health problem you had before 
the date a new insurance policy starts. 



Words in purple are 
defined on pages 82-85. 



Will My Pre-existing Condition Be Covered If I Buy A 
Medigap Policy? 

In some cases, a Medigap insurance company can refuse to 
cover health problems for up to 6 months, if you had the health 
problem before the policy started. This is called a 
"pre-existing condition waiting period." The insurance 
company can only use this kind of waiting period if your 
health problem was diagnosed or treated during the 6 months 
before the policy started. This means that the insurance 
company cannot make you wait for coverage of a pre-existing 
condition just because it thinks you should have known to see a 
doctor for a health problem because of the symptoms you had. 

Open Enrollment Period 

If you buy a policy during your Medigap open enrollment 
period, and you had at least six months of previous health 
coverage, called "creditable coverage" (see page 37), the 
company cannot give you any pre-existing condition waiting 
period. If you had less than six months of creditable coverage, 
this waiting period will be reduced by the number of months of 
creditable coverage you had. 

Special Medigap Protections (Guaranteed Issue Rights) 

If you buy a Medigap policy when you have Medigap 
protections or guaranteed issue rights, the insurance company 
cannot use a pre-existing condition waiting period at all (see 
page 41). 



If you are switching Medigap policies and want to know if you 
will have a pre-existing condition waiting period, see page 50. 



36 



Section 3: More Detailed Medigap Policy Information 



Creditable Coverage 

What Is Creditable Coverage? 

Creditable coverage is any previous health coverage you have that can reduce the 
time you have to wait before your pre-existing health conditions will be covered 
by a policy you buy during your Medigap open enrollment period. 

Your previous health coverage could have been any of the following: 

• A group health plan (like an employer plan) 

• A health insurance policy 

• Medicare Part A or Medicare Part B 

• Medicaid (see page 60) 

• A medical program of the Indian Health Service or tribal organization 

• A state health benefits risk pool 

• TRICARE (the health care program for military dependents and retirees [see 
pages 65-66]) 

• The Federal Employees Health Benefit Plan 

• A public health plan 

• A health plan under the Peace Corps Act 

Note: Whether you can use creditable coverage depends on whether you had any 
"breaks in coverage." If there was any time that you had no health coverage of any 
kind, and during that time, you were without coverage for more than 63 days in a row, 
you can only count creditable coverage that you had after that break in coverage. 



Creditable Coverage Example: 

Mr. Smith is 65 and has heart disease. His Medicare Part A and Part B started 
November 1, 2001. Before this date, he had no health insurance coverage. On 
March 1, 2002, Mr. Smith buys a Medigap policy. His Medigap insurance 
company refuses to cover his heart disease condition for 6 months (the pre- 
existing condition waiting period). However, since Mr. Smith had Medicare 
Part A and Part B from November 1 to March 1 , the insurance company must 
use his 4 months of Medicare coverage as creditable coverage to shorten this 
6-month waiting period. Now his waiting period will only be 2 months instead 
of 6 months. During these 2 months, after Medicare pays its share, Mr. Smith 
will have to pay the rest of the costs for the care of his heart disease. 



37 



Section 3: More Detailed Medigap Policy Information 



Medigap Policies For People Under Age 65 With 
A Disability Or End-Stage Renal Disease (ESRD) 

You may have Medicare before age 65 due to: 

• A disability, or 

• ESRD (permanent kidney failure requiring dialysis or 
a kidney transplant). 

If you are under age 65 and disabled or have ESRD, you may 
not be able to buy the Medigap policy you want until you turn 
65. Federal law does not require insurance companies to sell 
Medigap policies to people under age 65. However, some 
states require insurance companies to sell you a policy, at 
certain times, even if you are under age 65. 

During the first 6 months after you turn age 65 and are 
enrolled in Medicare Part B, you will get a Medigap open 
enrollment period. It does not matter that you have had 
Medicare Part B before you turned age 65. During this time: 

• You can buy any Medigap policy (including those 
policies that help pay the cost of prescription drugs), and 

• Insurance companies cannot refuse to sell you a 
Medigap policy due to a disability or other health 
problem, or charge you a higher premium than they 
charge other people who are 65 years old. 

When you buy a policy during your Medigap open enrollment 
period, the insurance company must shorten the waiting period 
for pre-existing conditions by the amount of creditable 
coverage you have. If you had Medicare for more than 6 
months before you turned 65 years old, you will not have a 
pre-existing condition waiting period because Medicare counts 
as creditable coverage. 

Several states require Medigap insurance companies to offer a 
limited Medigap open enrollment period for people with 
Medicare Part B who are under age 65. At the time of this 
printing, the following states require insurance companies to 



38 



Section 3: More Detailed Medigap Policy Information 



Medigap Policies For People Under Age 65 With 
A Disability Or End-Stage Renal Disease (ESRD) 
(continued) 

offer at least one kind of Medigap policy during a special open 
enrollment period to people with Medicare under age 65: 



• California 

• Connecticut 
a Kansas 

• Louisiana 

• Maine 

• Maryland 

• Massachusetts 



• Michigan 

• Minnesota 

• Missouri 

• Mississippi 

• New Hampshire 

• New Jersey 

• New York 



North Carolina 

Oklahoma 

Oregon 

Pennsylvania 

South Dakota 

Texas 

Wisconsin 




"I wasn't sure if I 
could buy a 
Medigap policy, so 
I called my State 
Health Insurance 
Assistance 
Program. They 
were very helpful 
and answered all 
of my questions." 
-Jim 



Also, some insurance companies will sell Medigap policies to 
people with Medicare under age 65. However, these policies 
may cost you more. Remember, if you live in a state that has a 
Medigap open enrollment period for people under age 65, you 
will still get another Medigap open enrollment period when 
you turn age 65. 

Also, if you join a Medicare + Choice plan and your coverage 
ends, you may have the right to buy a Medigap policy (see 
"Special Note For People With Medicare Under Age 65" on 
page 48). If you have questions, you should call your State 
Health Insurance Assistance Program (see pages 79-80). 

New right to suspend a Medigap policy for disabled people 
with Medicare 

If you are under 65, have Medicare, and have a Medigap 
policy, you have a new right to suspend your Medigap policy. 
This new right lets you suspend your Medigap policy benefits 
and premiums, without penalty, while you are enrolled in your 
or your spouse's employer group health plan. You can get your 
Medigap policy back at any time. 

If, for any reason, you lose your employer group health plan 
coverage, you can get your Medigap policy back. You must 
notify your Medigap insurance company that you want your 
Medigap policy back within 90 days of losing your employer 
group health plan coverage. 



39 



Section 3: More Detailed Medigap Policy Information 




New right to suspend a Medigap policy for disabled people with 
Medicare (continued) 

Your Medigap benefits and premiums will start again on the day your 
employer group health plan coverage stopped. The Medigap policy must 
have the same benefits and premiums it would have had if you had never 
suspended your coverage. Your Medigap insurance company can't refuse 
to cover care for any pre-existing conditions you have. So, if you are 
disabled and working, you can enjoy the benefits of your employer's 
insurance without giving up your Medigap policy. 

Information on Medicare Health Plans and 
Medigap Policies 

Choosing the right health coverage is an important - but sometimes 
difficult - decision. The new "Medicare Personal Plan Finder" helps you 
find information on your health plan options, including Medigap 
policies in your area. You will be able to get information about some of 
the insurance companies that sell Medigap policies in your state, how to 
contact these insurance companies, and, in some cases, how to compare 
your Medigap policy choices. 

You can get information three ways: 

1. Visit www.medicare.gov on the Web for fast results. Select "Medicare 
Personal Plan Finder." 



"I used my computer 
to get a great start on 
my search for the right 
Medigap policy." 
-Sue 



2. Call 1-800-MEDICARE (1-800-633-4227). For English, press (1) or 
for Spanish, press (2). Select option "0." A Customer Service 
Representative will help you. You will get your Medicare Personal 
Plan Finder results in the mail within three weeks. 

3. Call your State Health Insurance Assistance Program (see pages 79-80). 
Ask if they have a Medigap rate comparison shopping guide for your state. 

"Medicare Personal Plan Finder" Results 

When you use the "Medicare Personal Plan Finder," you will get a 
personalized summary page with general information to help you 
compare Medicare health plans and Medigap policies in your area. You 
can also get detailed information about the Medicare health plans and 
Medigap policies available in your area, or just the ones you are most 
interested in. You should plan to call more than one insurance company 
that sells Medigap policies in your state. Make sure the ones you call are 
honest and reliable (see page 56). 



40 



Section 3: More Detailed Medigap Policy Information 



Your Rights To Buy A Medigap Policy 



In some situtations, you have the right to buy a Medigap policy 
outside of your Medigap open enrollment period. These rights 
are called "Medigap Protections." They are also called 
guaranteed issue rights because the law says that insurance 
companies must issue you a policy. 



If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, you 

have the same 
rights to buy a 
Medigap policy. 
If you have 
questions, call 
your State 
Insurance 
Department 
(see pages 79-80). 



Words in purple are 
defined on pages 82-85. 



Medigap protections are important because without them, if 
you are not in your Medigap open enrollment period, an 
insurance company can refuse to sell you a policy, or you may 
be charged more for the policy. In addition, if you drop your 
Medigap policy, you may not be able to get it back except in 
very limited circumstances. 

In many cases, these rights apply when your health coverage 
changes. Remember, it is best not to wait until your current 
health coverage has almost ended before you apply for a 
Medigap policy. You can apply for a Medigap policy early (for 
example, while you are still in your health plan) and choose to 
start your Medigap coverage the day after your health plan 
coverage ends. This will prevent gaps in your health coverage. 

Summary of Medigap Protections (Guaranteed Issue Rights) 

There are a few situations involving health coverage changes 
where you may have a guaranteed issue right to buy a Medigap 
policy. 

In these situations, an insurance company: 

• can't deny you Medigap coverage or place conditions on a 
policy (like making you wait for coverage to start). 

• must cover you for all pre-existing conditions. 

• can't charge you more for a policy because of past or present 
health problems. 

The following page has a summary of these situations (see 
page 42). In order to get these Medigap protections, you must 
meet certain conditions. More detailed information on each 
situation will follow the summary. All rights to buy Medigap 
policies in the following situations include Medicare SELECT 
policies since they are a type of Medigap policy. 



41 



Section 3: More Detailed Medigap Policy Information 



Summary of Medigap Protections (continued) 

Important: In some situations, you have a guaranteed issue right to buy a Medigap policy because 
you lost certain kinds of health coverage. You should keep a copy of any letters, notices, and claim 
denials you get. Be sure to keep anything that has your name on it. Also, keep the postmarked 
envelope these papers come in. You may need to send a copy of some or all of these papers with your 
application for a Medigap policy to prove you lost coverage and have the right to these protections. 
The Medigap protections in this section are from federal law. Many states provide more Medigap 
protections than federal law. Call your State Health Insurance Assistance Program or State Insurance 
Department for more information (see pages 79-80). 

Situation #1 : Your Medicare + Choice plan or PACE program coverage ends 
because the plan is leaving the Medicare program or stops giving 
care in your area, see pages 43-44. 

Situation #2 : Your employer group health plan coverage ends, see page 44. 

Situation #3 : Your health coverage ends because you move out of the plan's 
service area, see page 45. 

Situation #4 : You joined a Medicare + Choice plan or PACE program when 
you were first eligible for Medicare at age 65. Within the first 
year of joining, you decide you want to leave, see page 45. 

Situation #5 : You dropped a Medigap policy to join a Medicare + Choice plan, 
Medicare SELECT policy, or PACE program for the first time and 
now you want to leave. You have been in the plan less than a year, 
see page 46. 

Situation #6 : Your Medigap insurance company goes bankrupt and you lose your 
coverage, or your Medigap policy coverage ends through no fault of 
your own, see page 46. 

Situation #7 :You leave your plan because your Medicare + Choice plan, or 
Medicare SELECT, or Medigap insurance company has 
committed fraud. For example, the marketing materials were 
misleading, or quality standards were not met, see page 47. 



42 



Note: There may be times when more than one situation applies to you. 
When this happens, you can choose the protection that gives you the best 
choice of policies. 



Section 3: More Detailed Medigap Policy Information 



The Programs of All- 
inclusive Care for the 
Elderly (PACE) 
combines medical, 
social, and long-term 
care services for frail 
people. PACE is 
available only in states 
that choose to offer it 
under Medicaid. For 
more information about 
PACE, see page 61. 



Medigap Protections 

Situation #1 : Your Medicare + Choice plan or PACE 
program coverage ends because the plan is leaving the 
Medicare program or stops giving care in your area. 



In this situation, your Medicare + Choice plan or PACE program 
sends you a letter telling you that you will no longer be covered 
by the plan. This may be because the plan is leaving the Medicare 
program or stops giving care in your area. If this happens, you 
have the right to buy Medigap plan A, B, C, or F that is sold in 
your state by any insurance company. You can buy the policy at 
the best premium price available, with no review of your medical 
records even if you have health problems. 



You can apply for a Medigap policy as soon as you get the final 
notification letter from your plan. When you get this letter telling 
you that your plan is leaving the Medicare program or will no 
longer give care in your area, you may have three choices: 

1 . Switch to another Medicare + Choice plan in your area. The 
final notification letter will tell you if there are other plans 
available in your area. In some cases, you may have to wait 
until the new plan you want to join is accepting new 
members. If you join a new Medicare + Choice plan when 
your current plan coverage ends, you will not need (or be 
able to use) a Medigap policy. 

2. Leave your Medicare + Choice plan or PACE program 
(disenroll) any time between the date you get your final 
notification letter and when your health coverage ends. 
Unless you join another Medicare + Choice plan, you will 
automatically return to the Original Medicare Plan when you 
leave (disenroll from) your plan or PACE program. You have 
63 calendar days from the day you leave your plan or PACE 
program to apply for a Medigap policy. 

3. Stay in your plan or PACE program until the date your 
coverage ends. Unless you join another Medicare + Choice 
plan, you will automatically return to the Original Medicare 
Plan when your coverage ends. You have 63 calendar days after 
your health coverage ends to apply for a Medigap policy. 



43 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #1: Your Medicare + Choice plan or PACE program 
coverage ends because the plan is leaving the Medicare program or 
stops giving care in your area, (continued) 

Important: You will have additional rights under Situation #4 (see 
page 45) or Situation #5 (see page 46) if this was the first time you 
were in a Medicare + Choice plan, you were in the plan less than one 
year before the plan left the Medicare program or stopped giving care 
in your area, and you choose to return to the Original Medicare Plan 
and apply for a Medigap policy. If instead, you immediately join 
another Medicare + Choice plan, you can stay in that plan for up to 
one year and still have the rights described in Situations #4 and #5. 

Situation #2: Your employer group health plan coverage ends. 

You are in an employer group health plan that pays some or all of the 
costs not paid by Medicare, but plan coverage ends because the 
employer goes out of business or cancels your company coverage. 
You have the right to buy Medigap plan A, B, C, or F that is sold in 
your state by any insurance company. You can buy the policy at the 
best premium price available, with no review of your medical records 
even if you have health problems. 

You may get a letter or a notice from your employer, the health plan, 
or insurance company telling you your coverage has been or will be 
cancelled. You have 63 calendar days from the date your coverage ends 
or from the date on the letter or notice (whichever is later) to apply for 
a Medigap policy. In some cases, you will not get a notice, but you 
may get a claim denial because your coverage has ended. If this 
happens, this claim denial is the same as a letter telling you that your 
coverage has ended. Remember, keep a copy of the letter, notice, claim 
denial, and postmarked envelope. You may need these papers to prove 
you lost coverage. You will need to send a copy of the letter, notice, or 
claim denial with your application in order to buy a Medigap policy. 



44 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #3: Your health coverage ends because you move 
out of the plan's service area. 

If you have health coverage from a Medicare + Choice plan, a 
Medicare SELECT policy, or you are in a PACE program, and 
you move out of the plan's service area, you will have to end 
your coverage. You have the right to buy Medigap plan A, B, C, 
or F that is sold in your state, or the state you are moving to, 
from any insurance company. You can buy the policy at the best 
premium price available, with no review of your medical 
records even if you have health problems. 

You must tell your current plan that you are moving and give 
them a date when you will end your coverage. You can apply for 
a Medigap policy as early as 60 calendar days before the date 
your health coverage ends. Remember, you must apply for a 
Medigap policy no later than 63 calendar days after your health 
coverage ends. 

Situation #4: You joined a Medicare + Choice plan or 
PACE program when you were first eligible for Medicare at 
age 65. Within the first year of joining, you decide you want 
to leave. 

If this happens, you have the right to buy any Medigap policy 
that is sold in your state by any insurance company. You can buy 
the policy at the best premium price available, with no review of 
your medical records even if you have health problems. You 
must tell the plan that you want to leave (disenroll) and give 
them a date to end your coverage. You will have from 60 
calendar days before your coverage ends until 63 calendar days 
after your coverage ends to apply for a new Medigap policy. 

Your rights under this situation may last for an extra 12 months 
if the plan you first joined leaves the Medicare program or 
stops giving care in your area before you have been in the plan 
for one year, AND you immediately join another Medicare + 
Choice plan or PACE program. 



45 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #5: You dropped a Medigap policy to join a Medicare + 
Choice plan, Medicare SELECT policy, or PACE program for the 
first time and now you want to leave. You have been in the plan 
less than a year. 

If this happens, you have the right to go back to your former Medigap 
policy, only if the same insurance company still sells it. You need to tell 
the Medicare + Choice plan, PACE program, or Medicare SELECT 
policy that you want to leave (disenroll) and give them a date to end 
your coverage. This date must be before you have been in the plan for a 
year. 

If your former Medigap policy is not available, you have the right to 
buy Medigap plan A, B, C, or F that is sold in your state by any 
insurance company. You can buy the policy at the best premium price 
available, with no review of your medical records even if you have 
health problems. You will have from 60 calendar days before your 
coverage ends until 63 calendar days after your coverage ends to apply 
for a new Medigap policy. 

Your rights under this situation may last for an extra 12 months if the 
plan you first joined leaves the Medicare program or stops giving 
care in your area before you have been in the plan for one year, AND 
you immediately join another Medicare + Choice plan or PACE 
program. 

Situation #6: Your Medigap insurance company goes bankrupt 
and you lose your coverage, or your Medigap policy coverage ends 
through no fault of your own. 

If this happens, you have the right to buy Medigap plan A, B, C, or F 
that is sold in your state by any insurance company. You can buy the 
policy at the best premium price available, with no review of your 
medical records even if you have health problems. You will have 63 
calendar days from the date your coverage ends to apply for a new 
Medigap policy. 



Words in purple are 
defined on pages 82-85. 



46 



Section 3: More Detailed Medigap Policy Information 



Medigap Protections (continued) 

Situation #7: You leave your plan because your Medicare + 
Choice plan, or Medicare SELECT, or Medigap insurance 
company has committed fraud. 

In this situation, you leave the health plan because it failed to 
meet its contract obligations to you. For example, the marketing 
materials were misleading, or quality standards were not met. 
Generally, you must have filed a grievance with the health plan, 
Medicare, or the State Insurance Department and received a 
favorable decision that the plan was at fault before you have this 
right. 

If this happens, you have the right to buy Medigap plan A, B, C, 
or F that is sold in your state by any insurance company. You 
can buy the policy at the best premium price available, with no 
review of your medical records even if you have health 
problems. You must tell the plan that you want to leave 
(disenroll) and give them a date to end your coverage. You will 
have 63 calendar days from the date your coverage ends to 
apply for a new Medigap policy. 



Remember, some states provide more Medigap protections. 
Your state may let you choose from more Medigap plans or 
give you a longer time to apply for a Medigap policy when 
you lose your coverage. Call your State Health Insurance 
Assistance Program (see pages 79-80). 



If you live in Massachusetts, Minnesota, or Wisconsin, you 

have the same rights to buy a Medigap policy. If you have 
questions, call your State Insurance Department 
(see pages 79-80). 



47 



Section 3: More Detailed Medigap Policy Information 



Special Note For People With Medicare Under Age 65: 

If you are in a situation that gives you the right to buy a 
Medigap policy, you must be allowed to buy Medigap plan A, 
B, C, or F that is sold in your state to people under age 65. You 
can buy the policy at the best premium price available, with no 
review of your medical records even if you have health 
problems. However, there is no federal law that says insurance 
companies must sell Medigap plans to people under age 65. If 
an insurance company does sell these Medigap policies to 
anyone under age 65, they must sell one to you if you are in one 
of these situations. 

If you have ESRD and are in a Medicare + Choice plan, and the 
plan leaves Medicare or no longer provides coverage in your area, 
you can join another Medicare + Choice plan if one is available in 
your area. This is true for people whose plans left Medicare or 
stopped providing coverage in their area on or after December 31, 
1998. 



Where To Get More Information About Medigap 
Protections 

• Call your State Health Insurance Assistance Program 
(see pages 79-80) to make sure that you qualify for these 
Medigap protections. They can also help you find 
the Medigap policy that's right for you. 

• Call your State Insurance Department (see pages 79-80) 
if you are denied Medigap coverage. 



48 



Section 3: More Detailed Medigap Policy Information 



Losing Medigap Coverage 

Can My Medigap Insurance Company Drop Me? 

In most cases, no. If you bought your Medigap policy after 
1990, the law says that your insurance company must let you 
renew your Medigap policy as long as you pay your premium. 
This means that the policy is guaranteed renewable. Your 
insurance company can drop you if you lie (for example, you 
commit fraud under the policy). Other than that, there is only 
one situation where you may lose a Medigap guaranteed 
renewable policy: if the insurance company goes bankrupt. If 
this happens, and state law does not make some other coverage 
available, you have the right to buy Medigap plan A, B, C, or F 
that is sold in your state (see Medigap Protections, Situation #6 
on page 46). 

Insurance companies in some states may refuse to renew 
Medigap policies that you bought before 1990. In order for an 
insurance company to refuse to renew one of these older 
Medigap policies, the company must get the state's approval 
and cancel all policies of this type that they sell in your state. If 
this happens, you have the right to buy Medigap plan A, B, C, 
or F that is sold in your state (see example below and Medigap 
Protections, Situation #6 on page 46). 



Words in purple are 
defined on pages 82-85. 



Example: 

In 1987, Mr. Jones bought a Medigap policy from Company 
X. The Medigap policy Mr. Jones bought is not guaranteed 
renewable because he bought it before 1990, and it did not 
say it was guaranteed renewable. Company X will not renew 
Mr. Jones's policy because it is no longer being offered. The 
company is canceling all policies of this type in the state. 
Therefore, Mr. Jones has the right to buy Medigap plan A, B, 
C, or F that is sold in his state. 



49 



Section 3: More Detailed Medigap Policy Information 



Switching Medigap Policies 

Do I Have To Switch If I Have An Older Medigap 
Policy? 

No. If you have an older Medigap policy, you can keep it. You 
don't have to switch it for one of the newer standardized 
Medigap plans. But, if you decide to switch your Medigap 
policy, you will not be able to go back to your older Medigap 
policy if you bought it before 1992 when standardized policies 
were first sold. 

What Should I Do Before Switching My Medigap 
Policy? 

Before switching policies, compare benefits and premiums. 
Some of the older Medigap policies may offer better coverage, 
especially for prescription drugs and long-term care. On the 
other hand, older Medigap policies may have bigger premium 
increases than newer standardized Medigap policies. 

Do I Have To Wait A Certain Length Of Time Before I 
Can Switch To A Different Medigap Policy? 

No, but the length of time you had your policy will affect how 
your new policy covers you for pre-existing conditions. 

Your new Medigap policy generally must cover all pre-existing 
conditions if you've had your current policy at least 6 months. 



Words in purple are 
defined on pages 82-85. 



Your new Medigap policy might not cover all pre-existing 
conditions if you've had your current Medigap policy for less 
than 6 months. However, the amount of time you've had your 
current Medigap policy must count towards the amount of time 
you must wait before your new policy covers your pre-existing 
condition. 



50 



Section 3: More Detailed Medigap Policy Information 



Do I Have To Wait A Certain Length Of Time Before I 
Can Switch To A Different Medigap Policy? (continued) 



If there is a benefit in the new Medigap policy that was not in 
your older policy, the company can make you wait up to 6 
months before covering that benefit. 



51 



Section 3: More Detailed Medigap Policy Information 



How Your Bills Get Paid 

Does The Medigap Insurance Company Pay My 
Doctor Or Provider Directly? 

When you have a Medigap policy, the insurance company must 
pay your doctor or provider directly when: 

• Your doctor or provider has signed an agreement with 
Medicare to accept assignment of all Medicare claims 
for all their Medicare patients, and 

• You tell your doctor's office to put on the Medicare 
claim form that you want Medigap insurance benefits 
paid to the doctor or supplier. Your doctor should put your 
Medigap policy number and the company name on the 
Medicare claim form. You will need to sign the claim 
form or have your doctor keep your signature on record. 
Make sure this information is correct. 

When these conditions are met, the Medicare carrier will 
process the claim and send it to the Medigap insurance 
company. A Medicare carrier is a private company that has a 
contract with Medicare to pay Part B bills. The carrier will send 
you a Medicare Summary Notice (MSN) or an Explanation of 
Medicare Benefits (EOMB). Your Medigap insurance company 
will pay your doctor or provider directly and then send you a 
notice. If you don't get this notice, you may ask your Medigap 
insurance company for it. 

In most cases, Medicare claims are sent directly to the 
insurance company, even if the doctor does not accept 
assignment on all claims. 



Words in purple are 
defined on pages 82-85. 



If Your Doctor Is Not Paid Directly 

If the Medigap insurance company does not pay your doctor 
directly when the above two conditions are met, you should report 
this to your State Insurance Department (see pages 79-80). For 
more information on Medigap claim filing by the carrier, call 
your Medicare carrier. Call 1-800-MEDICARE (1-800-633-4227) 
to get the telephone number of the Medicare carrier in your state. 
TTY users should call 1-877-486-2048. 



52 



Section 3: More Detailed Medigap Policy Information 



Private Contracts 

What Is A Private Contract? 

A private contract is an agreement between you and a doctor who 
has decided not to give services through the Medicare program. The 
private contract only applies to the services given by the doctor who 
asked you to sign it. 

If I Sign A Private Contract With My Doctor, Will Medicare 
And My Medigap Policy Pay? 

Medicare and Medigap policies will not pay for the services you get 
from the doctor with whom you have a private contract. You cannot 
be asked to sign a private contract in an emergency or urgent health 
situation. 

Note: You still have the right to see other Medicare doctors for 
services. 

If you sign a private contract with your doctor: 

• Medicare won't pay any amount for the services you get from this 
doctor. 

• Your Medigap policy, if you have one, will not pay 
anything for this service. 

• You will have to pay whatever this doctor or provider 

charges you for the services you get. Medicare's limiting charge 
will not apply. 

• Medicare + Choice plans will not pay for these services. 

• No claim should be submitted, and Medicare will not pay 
if one is submitted. 

• Many other insurance plans will not pay for the 
services either. Call your insurance company before you 
get the service if you have any questions. 

• Your doctor must tell you whether Medicare would pay for the 
service if you get it from another doctor who participates in 
Medicare. 



You may want to 
talk with 
someone in your 
State Health 
Insurance 
Assistance 
Program before 
signing a private 
contract (see 
pages 79-80). 



Your doctor must tell you if he or she has been excluded 
from the Medicare program. 



53 



Section 3: More Detailed Medigap Policy Information 



Private Contracts (continued) 



You can always choose to get services not covered under 
Medicare and pay for these services yourself. In this case, you 
do not have to sign a private contract, and your doctor does not 
have to stop giving services through Medicare. 



54 



Section 3: More Detailed Medigap Policy Information 



Watch Out for Illegal Insurance Practices 

It is illegal for anyone to: 

• Pressure you into buying a Medigap policy, or lie to 
you or mislead you to get you to switch from one 
company or policy to another. 

• Sell you a second Medigap policy when they know 
that you already have one, unless you tell the 
insurance company in writing that you plan to cancel 
your existing Medigap policy. 

• Sell you a Medigap policy if they know you have 
Medicaid, except in certain situations (see page 60). 

• Sell you a Medigap policy if they know you are 
enrolled in a Medicare + Choice plan. 

• Claim that a Medigap policy is part of the Medicare 
program or any other federal program. 

• Sell you a Medigap policy that can't legally be sold in 
your state. Some Medigap insurance companies use 
direct mail advertising to sell policies. Check with 
your State Insurance Department to make sure that the 
Medigap plan you are interested in can be sold in your 
state. 

• Misuse the names, letters, symbols, or emblems of the 
U. S. Department of Health and Human Services 
(DHHS), Social Security Administration (SSA), 
Centers for Medicare & Medicaid Services (CMS), or 
any of their various programs like Medicare. 

If you believe that a federal law has been broken, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. In most cases, however, your State Insurance 
Department can help you with insurance-related problems (see 
pages 79-80). 



55 



Section 3: More Detailed Medigap Policy Information 



Ways To Check If An Insurance Company Is Reliable 

Buying a Medigap policy is an important decision. You want to make 
sure that you are buying from a reliable insurance company. To help 
you find out if an insurance company is reliable, you can: 

• Call the State Insurance Department in your state (see 
pages 79-80). Ask if they keep a record of complaints against 
insurance companies and whether these can be shared with you. 

• Go to your local public library. Your local public library can 
help you: 

• Get information on an insurance company's financial 
strength by independent rating services such as, Weiss 
Rating, Inc., A.M. Best, and Standard & Poors. 

• Look at information on the Web. 

• Talk to someone you trust, like your insurance agent or a 
friend who has a Medigap policy. 

• Call the State Health Insurance Assistance Program 
in your state (see pages 79-80). These programs can 
give you free help with buying a Medigap policy. 



Words in purple are 
defined on pages 82-85. 



56 



Section 4: 

Other Insurance and 

Ways To Pay Health Care 

Costs 




"This section has helpful information about 
paying for your health care." 
-Ana Maria 



57 



Section 4: Other Insurance and Ways To Pay Health Care Costs 



There are other kinds of health coverage, besides a Medigap policy, 
that may pay for some of your health care costs not covered by 
Medicare. They include: 

1. Medicare Savings Programs (help from your state) (see page 59) 

2. Medicaid (see page 60) 

3. The PACE Program (Programs of All-inclusive Care for the 
Elderly) (see page 61) 

4. Federally Qualified Health Centers (FQHCs) (see page 62) 

5. Home and Community-Based Service/Waiver Programs (HCBS) 
(see page 62) 

6. Employee or Retiree Coverage From an Employer or Union (see 
page 63) 

7. COBRA Coverage (see pages 63-64) 

8. Long-Term Care Insurance (see page 65) 

9. Veterans' Benefits (see page 65) 

10. TRICARE for Life/Military Retiree Benefits (see pages 65-66) 

1 1 . Prescription Drug Assistance Programs (see page 66) 

12. Hospital Indemnity Insurance (see page 66) 

13. Specified Disease Insurance (see page 66) 

For more information about these kinds of health insurance and ways 
to pay health care costs, call 1-800-MEDICARE (1-800-633-4227). 
TTY users should call 1-877-486-2048. Ask for a free copy of the 
Health Care Coverage Directory for People with Medicare (CMS 
Pub. No. 02231) and Medicare and Other Health Benefits: Your 
Guide to Who Pays First (CMS Pub. No. 02179). You can also read 
or print a copy of these booklets at www.medicare.gov on the Web. 
Select "Publications." 



58 



Section 4: Other Insurance and Ways To Pay Health Care Costs 



Medicare Savings 
Programs may not be 
available in Guam, 
Puerto Rico, the 
Virgin Islands, the 
Northern Mariana 
Islands, and 
American Samoa. 



1 . Medicare Savings Programs (Help From Your State) 

There are programs that help millions of people with Medicare save 
money each year. States have programs for people with limited 
income and resources that pay some or all of Medicare's premiums. 
Some programs may also pay Medicare deductibles and 
coinsurance. 

You can apply for these programs if: 

• You have Medicare Part A. (If you pay a premium for Medicare 
Part A but don't think you can afford to keep paying it, there is a 
program that may pay the Medicare Part A premium for you.), and 

• You are a person with resources of $4,000 or less, or a couple with 
resources of $6,000 or less. Resources include things like money in 
a checking or savings account, stocks, or bonds, and 

• You are a person with a monthly income of less than $1,313,* or a 
couple with a monthly income of less than $1,762.* 

* Income limits will change slightly in 2003. If you live in Alaska or 
Hawaii, income limits are slightly higher. 

Note: Individual states may have more generous income and/or 
resource requirements. 

Call your State Medical Assistance Office and ask for information on 
Medicare Savings Programs. Look in the "blue pages" section of your local 
telephone directory for the telephone number. Or, call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. It's very 
important to call if you think you qualify for any of these Medicare Savings 
Programs, even if you aren't sure. 



Words in purple are 
defined on pages 82-85. 



Insure Kids Now 

Free or low-cost health insurance is available now in your 
state for uninsured children under age 19. Call toll-free, 
1-877-KIDS-NOW (1-877-543-7669) for more 
information. 



59 



Section 4: Other Insurance and Ways To Pay Health Care Costs 



2. Medicaid 



Medicaid is a joint federal and state program that helps pay medical costs for some 
people with limited incomes and resources. Most of your health care costs are covered 
if you have Medicare and Medicaid. Medicaid programs vary from state to state. 
People with Medicaid may get coverage for nursing home care and outpatient 
prescription drugs that are not covered by Medicare. For more information about 
Medicaid, call your State Medical Assistance Office. 

What should I do if I have a Medigap policy and then go on Medicaid? 

You have the right to suspend the Medigap policy rather than dropping it while you are 
on Medicaid. However, in some cases, it may not be a good idea to suspend your 
Medigap policy. Call your State Medical Assistance Office to help you with this 
decision. 

If you do suspend your policy, while it is suspended, you do not pay premiums and it 
will not pay benefits. You can only suspend a Medigap policy for up to two years. At 
the end of the suspension, you can start it up again without new medical underwriting 
or pre-existing condition waiting periods. Call your insurance company to find out 
how to suspend a policy. 

Can An Insurance Company Sell Me A Medigap Policy If I 
Already Have Medicaid? 

If you have Medicaid, an insurance company can sell you a Medigap 
policy only in certain situations (see chart below). 



If Medicaid pays your 
Medigap policy premium... 


The insurance company can 
legally sell you any Medigap 
policy 


If Medicaid pays your 
Medicare premiums, 
deductibles, or coinsurance... 


The insurance company can 
legally sell you Medigap plans 
H, I, or J 


If Medicaid only pays all or 
part of your Medicare Part B 
premium... 


The insurance company can 
legally sell you any Medigap 
policy 



In any other situation, it is illegal for an insurance company to 
sell you a Medigap policy if you have Medicaid. 



60 



Section 4: Other Insurance and Ways To Pay Health Care Costs 

3. The PACE Program (Programs of All-inclusive Care 
for the Elderly) 

PACE combines medical, social, and long-term care 
services for frail people. PACE is available only in states 
that have chosen to offer it under Medicaid. To be eligible, 
you must: 

• Be age 55 or older, 

• Live in the service area of a PACE program, 

• Be certified as eligible for nursing home care by the 
appropriate state agency, and 

• Be able to live safely in the community. 

If you are enrolled in a PACE program, you may have to 
pay a monthly premium depending on your Medicare or 
Medicaid eligibility. 

Services are given by a team of health care professionals. 
The services are usually given in a PACE center and 
include home and transportation services. Services include 
primary health services, physical and occupational therapy, 
social services, personal care and support services, 
nutrition counseling, and meals. The goal of PACE is to 
help people stay independent and living in their community 
as long as possible, while getting the high quality care they 
need. 



Words in purple are 
defined on pages 82-85. 



To find a PACE site near you, or for more information, call 
your State Medical Assistance Office. Look in the "blue pages" 
section of your local telephone directory for the telephone 
number. Or, call 1-800-MEDICARE (1-800-633-4227). TTY 
users should call 1-877-486-2048. You can also look on the 
Web at www.medicare.gov/Nursing/Alternatives/PACE.asp 
for PACE locations and telephone numbers. 



61 



Section 4: Other Insurance and Ways To Pay Health Care Costs 

4. Federally Qualified Health Centers (FQHCs) 

These are special health centers that can give you routine 
health care at a lower cost. FQHCs may include: 

• A community health center, 

• Tribal health clinic, 

• Migrant health service, and 

• Health center for the homeless. 

To find the FQHC nearest you, look at www.medicare.gov 
on the Web. Select "Helpful Contacts." Or, call 
1-800-MEDICARE (1-800-633-4227). TTY users should 
call 1-877-486-2048. Ask for the telephone number of the 
Primary Care Association in your state. 

5. Home and Community-Based Service/Waiver 
Programs (HCBS) 

The HCBS programs offer different choices to some people 
with Medicaid. If you qualify, you will get care in your 
home and community so you can stay independent and 
close to your family and friends. HCBS programs help the 
elderly and disabled, mentally retarded, developmentally 
disabled, and certain other disabled adults. These programs 
give quality and low cost services. 

To get more information on HCBS programs, services, and 
who is eligible in your state, call your State Medical 
Assistance Office. Look in the "blue pages" section of 
your local telephone directory for the telephone number. 
Or, call 1-800-MEDICARE (1-800-633-4227). TTY users 
should call 1-877-486-2048. You can also look on the Web 
at www.medicare.gov. Select "Helpful Contacts." Select 
the state you want and select "Other Health Insurance 
Programs." 



62 



Section 4: Other Insurance and Ways To Pay Health Care Costs 

6. Employee or Retiree Coverage From an Employer or 
Union 



Words in purple are 
defined on pages 82-85. 



Call your benefits administrator to find out if you have or can get 
health care coverage based on your or your spouse's past or current 
employment. Since this kind of health coverage is not a Medigap 
policy, the rules that apply to Medigap policies do not apply. 

Note: When you have retiree coverage from an employer or union, 
they have control over this coverage. They may change the benefits 
or premiums, and may also cancel the coverage if they choose. 



Caution: If you drop your employer or union group health 
coverage, you may not be able to get it back. For more 
information, call your benefits administrator. 



Important: If the employer or union health coverage ends, you may 
have the right to buy a Medigap policy. Your employer or union must 
tell you within 60 calendar days after the date your coverage ends. If 
they don't, then your only notice that your coverage has ended could 
be a letter telling you that your claim for payment has been denied, 
or that a claim your doctor sent in for payment was denied (see 
Medigap Protections, Situation #2 on page 44). 

7. COBRA Coverage 

COBRA (The Consolidated Omnibus Budget Reconciliation Act of 
1985) is a law that lets employees and their dependents keep their 
group health coverage for a time after they leave their group health 
plan under certain conditions. This is called "continuation coverage." 

You may have this right if you lose your job or have your working 
hours reduced. You may also have this right if you are covered under 
your spouse's plan and your spouse dies or you get divorced. 

COBRA generally lets you and your dependents keep the group 
coverage for 18 months (or up to 29 or 36 months in some cases). 
You may have to pay both your share and the employer's share of the 
premium. 



63 



Section 4: Other Insurance and Ways To Pay Health Care Costs 



This law only applies to employers with 20 or more 
employees. Some state laws require employers with less 
than 20 employees to let you keep your group health 
coverage for a time. You can call your State Insurance 
Department (see pages 79-80) to find out if your state has 
this law or to get more information about group health 
coverage under COBRA. In most situations that give you 
COBRA rights, other than a divorce, you should get a notice 
from your benefits administrator. If you don't get a notice, 
or if you get divorced, you should call your benefits 
administrator as soon as possible. 



For more 
information about 
COBRA, look at 
www.dol.gov/pwba/ 
public/health. htm 
on the Web. 



Medicare and Continuation Coverage Under COBRA 

If you already have continuation coverage under COBRA 
when you enroll in Medicare, your COBRA may end. This 
is because the employer has the option of canceling the 
continuation coverage at this time. The length of time your 
spouse may get coverage under COBRA may change when 
you enroll in Medicare. 

However, if you choose COBRA coverage after you enroll 
in Medicare, you can keep your continuation coverage. If 
you only have Medicare Part A when your group health plan 
coverage ends (based on current or active employment), 
you can enroll in Medicare Part B during a special 
enrollment period without having to pay a Medicare Part B 
premium penalty. This means you have to sign up for 
Medicare Part B within 8 months after your group health 
coverage ends or whenever employment ends, whichever is 
first (see pages 7-8). You will not get another Special 
Enrollment Period once COBRA coverage ends. 



Remember, once you're age 65 or older and enrolled in 
Medicare Part B, the Medigap open enrollment period starts 
and cannot be changed (see page 18). 



64 



State law may give you the right to continue your coverage 
under COBRA beyond the point COBRA coverage would 
ordinarily end. Your rights will depend on what is allowed 
under the state law. For more information about your state's 
law, call your State Insurance Department (see pages 79-80). 



Section 4: Other Insurance and Ways To Pay Health Care Costs 

8. Long-Term Care Insurance 

This kind of insurance is sold by private insurance companies 
and usually covers medical care and non-medical care to help 
you with your personal daily needs, such as bathing, dressing, 
using the bathroom, and eating. Generally, Medicare does not 
pay for long-term care. For more information about long-term 
care insurance, get a copy of A Shopper's Guide to Long-Term 
Care Insurance from either your State Insurance Department 
(see pages 79-80) or the National Association of Insurance 
Commissioners, 2301 McGee Street, Suite 800, Kansas City, 
MO 64108-3600. You may also get a free copy of Choosing 
Long-Term Care (CMS Pub. No. 02223) by calling 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

9. Veterans' Benefits 

If you are a Veteran, call the U.S. Department of Veterans 
Affairs at 1-800-827-1000 for information about Veterans' 
benefits and services available in your area. 

10. TRICARE for Life/Military Retiree Benefits 

TRICARE for Life (TFL) provides expanded medical 
coverage for: Medicare-eligible uniformed services retirees, 
including retired National Guard members and reservists; 
Medicare-eligible family members and widow/widowers; 
and certain former spouses if they were eligible for 
TRICARE before age 65. You must have Medicare Part B to 
be eligible for TFL. 

If eligible, you get all Medicare-covered benefits under the 
Original Medicare Plan, plus all TFL-covered benefits. 



65 



Section 4: Other Insurance and Ways To Pay Health Care Costs 



10. TRICARE for Life/Military Retiree Benefits (continued) 

If you use a Medicare provider, Medicare will be the first payer for 
all Medicare-covered services, and TFL will be the second payer. 
TFL will generally pay all Medicare copayments and deductibles and 
cover most of the costs of certain care not covered by Medicare. For 
more information on TFL, call 1-888-DOD-LIFE (1-888-363-5433) 
or look at www.TRICARE.osd.mil on the Web. Call 1-800-538-9552 
for other military retiree benefit questions. 

11. Prescription Drug Assistance Programs 

There are programs that may offer you discounts or free medication. 
For more information, look at www.medicare.gov on the Web. Select 
"Prescription Drug Assistance Programs." If you don't have a 
computer, your local senior center or library may be able to help you 
get this information. Or, call 1-800-MEDICARE (1-800-633-4227) 
and ask for information about these programs. TTY users should call 
1-877-486-2048. 

12. Hospital Indemnity Insurance 

This kind of insurance pays a certain cash amount for each day you 
are in the hospital up to a certain number of days. It does not fill 
gaps in your Medicare coverage. Remember, Medicare and any 
Medigap policy you have will very likely cover costs from any 
hospital stay you have. Therefore, you may not need this insurance. 

Note: This kind of insurance is not considered creditable coverage. 



13. Specified Disease Insurance 

This kind of insurance pays benefits for only a single disease, such as 
cancer, or for a group of diseases. It does not fill gaps in your 
Medicare coverage. Remember, Medicare and any Medigap policy 
you have will very likely cover costs from any specific disease you 
have. Therefore, you may not need this insurance. 



Note: This kind of insurance is not considered creditable coverage. 






66 



Section 5: 
Coverage Charts 




"I used the Preventive Service chart to see if 
diabetes services were covered." 
-Harry 



67 



Section 5: Coverage Charts 



Medicare Part A and Part B Coverage Charts 

For: See page(s): 

Medicare Part A (Hospital Insurance) 69 

Medicare Part B (Medical Insurance) 70-72 

If you have general questions about Medicare Part A, call your 
Fiscal Intermediary. A Fiscal Intermediary is a private 
company that has a contract with Medicare to pay Medicare 
Part A and some Medicare Part B bills. 

If you have general questions about Medicare Part B, call your 
Medicare carrier. A Medicare carrier is a private company that 
has a contract with Medicare to pay Medicare Part B bills. 

If you have questions about durable medical equipment, 
including diabetic supplies, call your Durable Medical 
Equipment Regional Carrier (DMERC). A DMERC is a 
private company that has a contract with Medicare to pay bills 
for durable medical equipment. 

To get these telephone numbers, call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 

You can also get these telephone numbers at 
www.medicare.gov on the Web. Select "Helpful Contacts." 

Charts of Standardized Medigap Plans 

For: See page: 

Massachusetts 73 

Minnesota 74 

Wisconsin 75 

All other states 14 

For more information about these Medigap plans, call your 
State Insurance Department (see pages 79-80) or look at 
www.medicare.gov on the Web. Select "Medicare Personal 
Plan Finder." 



68 



COVERED SERVICES IN MEDICARE PART A 



Medicare Part A (Hospital Insurance) 
Helps Pay For: 


What YOU Pay in 2002* in the Original 
Medicare Plan 


Hospital Stays: Semiprivate room, meals, general 
nursing, and other hospital services and supplies. This 
includes care you get in critical access hospitals and 
inpatient mental health care. This does not include 
private duty nursing, or a television or telephone in 
your room. It also does not include a private room, 
unless medically necessary. 


For each benefit period YOU pay: 

• A total of $812 for a hospital stay of 1-60 days. 

• $203 per day for days 6 1 -90 of a hospital stay. 

• $406 per day for days 91-150 of a hospital stay. 
(See Lifetime Reserve Days on page 83.) 

• All costs for each day beyond 150 days. 


Skilled Nursing Facility (SNF) Care: 

Semiprivate room, meals, skilled nursing and 
rehabilitative services, and other services and supplies 
(after a related 3 -day hospital stay). 


For each benefit period YOU pay: 

• Nothing for the first 20 days. 

• Up to $101.50 per day for days 21-100. 

• All costs beyond the 100th day in the benefit period. 

If you have questions about SNF care and conditions of 
coverage, call your Fiscal Intermediary . 


Home Health Care: Part-time skilled nursing care, 
physical therapy, occupational therapy, speech- 
language therapy, home health aide services, durable 
medical equipment (such as wheelchairs, hospital 
beds, oxygen, and walkers) and medical supplies, and 
other services. 


YOU pay: 

• Nothing for home health care services. 

• 20% of the Medicare-approved amount for durable 
medical equipment. 

If you have questions about home health care and 
conditions of coverage, call your Regional Home Health 
Intermediary. 


Hospice Care: Medical and support services, from 
a Medicare-approved hospice for people with a 
terminal illness, drugs for symptom control and pain 
relief, and other services not otherwise covered by 
Medicare. Hospice care is usually given in your 
home. However, short-term hospital and inpatient 
respite care (care given to a hospice patient so that 
the usual caregiver can rest) are covered when 
needed. 


YOU pay: 

• A copayment of up to $5 for outpatient prescription drugs and 5% of the 
Medicare-approved payment amount for inpatient respite care. The amount 
you pay for respite care can change each year. Room and board is generally 
not payable by Medicare except in certain cases. For example, room and 
board are not covered if you receive general hopsice services while a 
resident of a nursing home or a hospice's residential facility However, 
room and board are covered for inpatient respite care and during short-term 
hospital stays. If you have questions about hospice care and conditions of 
coverage, call your Regional Home Health Intermediary. 


Blood: Pintsof blood you get at a hospital or skilled 
nursing facility during a covered stay. 


YOU pay: 

• For the first 3 pints of blood, unless you or someone 
else donates blood to replace what you use. 



* New Medicare Part A and Part B amounts will be available by January 1, 2003. 

If you have general questions about Medicare Part A, call your Fiscal Intermediary. To get the telephone numbers for 
Fiscal Intermediaries or Regional Home Health Intermediaries, look at www.medicare.gov on the Web. Select 
"Helpful Contacts." Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 69 



COVERED SERVICES IN MEDICARE PART B 



Medicare Part B (Medical Insurance) 
Helps Pay For: 


What YOU pay in 2002* in the 
Original Medicare Plan 


Medical and Other Services: Doctors' services (not 
routine physical exams), outpatient medical and 
surgical services and supplies, diagnostic tests, 
ambulatory surgery center facility fees for approved 
procedures, and durable medical equipment (such as 
wheelchairs, hospital beds, oxygen, and walkers). Also 
covers second surgical opinions, outpatient physical 
and occupational therapy, including speech-language 
therapy, and outpatient mental health care. 


YOU pay: 

• $100 deductible (once per calendar year). 

• 20% of the Medicare-approved amount after the 
deductible. 

• 20% for all outpatient physical, occupational, and 
speech-language therapy services. 

• 50% for outpatient mental health care. 


Clinical Laboratory Service: Blood tests, 
urinalysis, and more. 


YOU pay: 

• Nothing for Medicare-approved services. 


Home Health Care: Part-time skilled nursing care, 
physical therapy, occupational therapy, speech-language 
therapy, home health aide services, medical social 
services, durable medical equipment (such as 
wheelchairs, hospital beds, oxygen, and walkers) and 
medical supplies and other services. 


YOU pay: 

• Nothing for Medicare-approved services. 

• 20%o of the Medicare-approved amount for durable 
medical equipment. 


Outpatient Hospital Services: Hospital services 
and supplies received as an outpatient as part of a 
doctor's care. 


YOU pay: 

• A coinsurance or copayment amount, which may 
vary according to the service. 


Blood: Pints of blood you get as an outpatient or as 
part of a Part B covered service. 


YOU pay: 

• For the first 3 pints of blood, then 20% of the 
Medicare-approved amount for additional pints of 
blood (after the deductible), unless you or someone 
else donates blood to replace what you use. 



* New Medicare Part A and Part B amounts will be available by January 1, 2003. 

Note: Actual amounts you must pay may be higher if the doctor or supplier does not accept assignment and you 
may have to pay the entire charge at the time of service. If you have general questions about Medicare Part B, 
call your Medicare carrier. If you have questions about durable medical equipment, including diabetic supplies, call 
your Durable Medical Equipment Regional Carrier (DMERC). For their telephone numbers, look at 
www.medicare.gov on the Web. Select "Helpful Contacts." Or, call 1-800-MEDICARE (1-800-633-4227). 
TTY users should call 1-877-486-2048. 



70 



MEDICARE PART B PREVENTIVE SERVICES 



Medicare Part B Covered 


Who is 


What YOU pay in the 


Preventive Services 


covered... 


Original Medicare Plan... 


Bone Mass Measurements: 


* Certain people with Medicare 


20% of the Medicare-approved amount 


Frequency of testing varies with your 


who are at risk for losing bone 


(or a copayment amount) after the 


health status. 


mass including women with 
low levels of the female 
hormone estrogen, and people 
who have had broken bones in 
the past, or who are already 
being treated for osteoporosis. 


yearly Part B deductible. 


Colorectal Cancer Screening: 


All people with Medicare 


Nothing for the fecal occult blood test. 


• Fecal Occult Blood Test - Once 


age 50 and older. However, 


For all other tests, 20% of the 


every 12 months. 


there is no minimum age for 


Medicare-approved amount after the 


• Flexible Sigmoidoscopy - Once 


having a colonoscopy. 


yearly Part B deductible. 


every 48 months. 






• Colonoscopy - Once every 24 




For flexible sigmoidoscopy or 


months if you are at high risk for 




colonoscopy, you pay 25% of the 


colon cancer. If you are not at high 




Medicare-approved amount if the test is 


risk for colon cancer, once every 10 




done in an ambulatory surgical center 


years, but not within 48 months of a 




or hospital outpatient department. 


screening flexible sigmoidoscopy. 






• Barium Enema - Doctor can use this 






instead of flexible sigmoidoscopy or 






colonoscopy. 






Diabetes Services and Supplies: 


All people with Medicare 


20%) of the Medicare-approved amount 


• Coverage for glucose monitors, test 


who have diabetes (insulin 


after the yearly Part B deductible. 


strips, and lancets. 


users and non-users). 




• Diabetes self-management training. 


Certain people with 
Medicare who are at risk for 
complications from diabetes, 
if requested by your doctor 






or other provider. 




Mammogram Screening: 


All women with Medicare 


20%> of the Medicare-approved amount 


Once every 12 months. Medicare 


age 40 and older. You can 


with no Part B deductible. 


covers new digital technologies for 


also get one baseline 




mammogram screenings. 


mammogram between ages 
35 and 39. 





* For more information about bone mass measurement, look on the Web at www.medicare.gov and select "Frequently Asked 
Questions" or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 

71 



MEDICARE PART B PREVENTIVE SERVICES (CONTINUED) 



Medicare Part B Covered 
Preventive Services 


Who is 
covered... 


What YOU pay in the 
Original Medicare Plan... 


Pap Test and Pelvic Examination: 

Once every 24 months (Includes a 
clinical breast exam). 

Once every 12 months if you are at 
high risk for cervical or vaginal 
cancer, or if you are of childbearing 
age and have had an abnormal Pap 
test in the past 36 months. 


All women with 
Medicare. 


Nothing for the Pap lab test. For Pap 
test collection, and pelvic and breast 
exams, 20% of the Medicare-approved 
amount (or a copayment amount) with 
no Part B deductible. 


Prostate Cancer Screening: 

• Digital Rectal Examination - Once 
every 12 months. 

• Prostate Specific Antigen (PSA) 
Test - Once every 12 months. 


All men with Medicare age 
50 and older. 


Generally, 20% of the Medicare- 
approved amount for the digital rectal 
exam after the yearly Part B deductible. 
No coinsurance and no Part B 
deductible for the PSA Test. 


Shots (vaccinations): 

• Flu Shot - Once a year in the fall or 
winter. 

• Pneumococcal Pneumonia Shot - 
One shot may be all you will ever 
need. Ask your doctor. 

• Hepatitis B Shot 


All people with Medicare. 
All people with Medicare. 

Certain people with 
Medicare at medium to high 
risk for Hepatitis B. 


Nothing for flu and pneumococcal 
pneumonia shots if the health care 
provider accepts assignment. 

For Hepatitis B shots, 20% of the 
Medicare-approved amount (or a 
copayment amount) after the yearly Part 
B deductible. 


Glaucoma Screening: 

Once every 12 months. Must be done 
or supervised by an eye doctor who is 
legally allowed to do this service in 
your state. 


All people with Medicare 
who are at high risk for 
glaucoma, including people 
with diabetes or a family 
history of glaucoma. 


20% of the Medicare-approved amount 
after the yearly Part B deductible. 



72 



Section 5: Coverage Charts 



Chart Of Standardized Medigap Plans In Massachusetts 

Basic Benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance and the cost of 365 extra 
days of hospital care during your lifetime after Medicare coverage ends. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare- 
approved payment amount). 

• Blood: Covers the first 3 pints of blood each year. 



Medigap Benefits 


Core 
Plan 


Supplement 1 
Plan 


Supplement 2 
Plan 


Basic Benefits 


/ 


/ 


/ 


Medicare Part A: Inpatient 
Hospital Deductible 




/ 


/ 


Medicare Part A: Skilled-Nursing 
Facility Coinsurance 




/ 


/ 


Medicare Part B: Deductible 




/ 


/ 


Foreign Travel 
Emergency 




/ 


/ 


Inpatient Days in Mental 
Health Hospitals 


60 days per 
calendar year 


120 days per 
benefit year 


120 days per 
benefit year 


Prescription Drugs 

($35 deductible each calendar 
quarter, then 100% coverage for 
generic drugs and 80%> coverage for 
brand name drugs) 






/ 


State-Mandated Benefits 

(Annual Pap tests and 
mammograms. Check your plan 
for other state-mandated benefits.) 


/ 


/ 


/ 



For more information on these policies, call your State Insurance Department (see pages 
79-80) or look at www.medicare.gov on the Web. Select "Medicare Personal Plan Finder." 

Note: The checkmarks in this chart mean the benefit is covered under that plan. 



73 



Section 5: Coverage Charts 



Chart Of Standardized Medigap Plans In Minnesota 

Basic Benefits - Included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 
20% of the Medicare-approved payment amount). 

• Blood: Covers the first 3 pints of blood each year. 



ivi^uiyap Ddidiia 


Dddll/ l-lclll 


Plan 


Basic Benefits 


/ 


/ 


Medicare Part A: Inpatient 
Hospital Deductible 




/ 


Medicare Part A: Skilled- 
Nursing Facility Coinsurance 


/ 


/ 


Medicare Part B: Deductible 




/ 


Foreign Travel 
Emergency 


80% 


80%* 


Outpatient Mental Health 


50% 


50% 


Usual and Customary Fees 




80%* 


Preventive Care 


/ 


/ 


Prescription Drugs 




80% 


At-home Recovery 




/ 


Physical Therapy 


20% 


20% 


Coverage while in a 
Foreign Country 




80%* 


State Mandated Benefits: 
Diabetic equipment 
and supplies, routine cancer 
screening, reconstructive surgery, 
and immunizations. 


/ 


/ 



Optional Riders 



• Medicare Part A: 
Inpatient Hospital 
Deductible 

• Medicare Part B: 
Deductible 

• Usual and Customary 
Fees 

• Preventive Care 

• Prescription Drugs 

• At-home recovery 

Insurance companies are 
allowed to offer six 
additional riders that can 
be added to a Basic plan. 
You may choose any one 
or all of the riders to 
design a Medigap plan that 
meets your needs. 



*The policy pays 100% after you spend $1000 of out-of-pocket expenses for a calendar year. 
74 Note: The checkmarks in this chart mean the benefit is covered under that plan. 



Section 5: Coverage Charts 



Chart Of Standardized Medigap Plans In Wisconsin 

Basic Benefits - Included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of 
the Medicare-approved payment amount). 



Blood: Covers the first 3 pints of blood each year. 



Medigap Benefits 


Basic Plan 


Basic Benefits 


/ 


Medicare Part A: Skilled- 
Nursing Facility 
Coinsurance 


/ 


Inpatient Mental 
Health Coverage 


1 75 days per lifetime in 
addition to Medicare 


Home Health Care 


40 visits in addition to 
those paid by Medicare 


Medicare Part B: 
Coinsurance 


/ 


Outpatient Mental Health 


/ 


Prescription Drugs (after 
a deductible of $6,250, 
pays 80%) 


/ 



Optional Riders 



• Medicare Part A Deductible 

• Additional Home Health Care 
(365 visits including those 
paid by Medicare) 

• Medicare Part B Deductible 

• Medicare Part B Excess 
Charges 

• Outpatient Prescription Drug 

• Foreign Travel 

Insurance companies are 
allowed to offer additional 
riders to a Medigap plan. 



Wisconsin also has many other state mandated benefits under the Medigap Basic 
Plan. For more information, call your State Insurance Department (see pages 79-80) 
or look at www.medicare.gov on the Web. Select "Medicare Personal Plan Finder." 

Note: The checkmarks in this chart mean the benefit is covered under that plan. 



75 



NOTES 




"It is nice to know there is 
somewhere to go to get more 
information." 

-Mike 



76 



Section 6: 
For More Information 




"You can call 
1-800-MEDICARE 
(1-800-633-4227) 24 hours a 
day, including weekends. 
TTY users can call 
1-877-486-2048." 

-Elizabeth 




"We visit www.medicare.gov for free Medicare 
information." 

-Greg and Linda 



77 



Section 6: For More Information 



In this section, you will find telephone numbers to call for help with your 
questions. These telephone numbers were correct at the time of printing. 
Telephone numbers sometimes change. You can find the most up-to-date 
telephone numbers by looking at www.medicare.gov on the Web. Select 
"Helpful Contacts." Or, call 1-800-MEDICARE (1-800-633-4227). 
TTY users should call 1-877-486-2048. 



Where To Get More Information 

• Call your State Health Insurance Assistance Program for help with: 

• buying a Medigap policy, or long-term care insurance, 

• dealing with payment denials or appeals, 

• Medicare rights and protections, 

• complaints about your care or treatment, 

• choosing a Medicare health plan, or 

• Medicare bills. 

• Call your State Insurance Department if you have questions about 
the Medigap policies sold in your area and any insurance related 
problems. 



78 



Section 6: For More Information 



State Name 


State Health Insurance Assistance 
Program 


State Insurance 
Department 


Alabama 


1(800)243-5463 


1(800)433-3966 in-state calls only 


Alaska 


1(800)478-6065 in-state calls only 


1(800)467-8725 in-state calls only 


American Samoa 


1(888)875-9229 


1(684)633-4116 


Arizona 


1(800)432-4040 


1(800)325-2548 in-state calls only 


Arkansas 


1(800)224-6330 


1(800)224-6330 


California 


1(800)434-0222 


1(800)927-4357 in-state calls only 


Colorado 


1(888)696-7213 


1(800)930-3745 in-state calls only 


Connecticut 


1(800)994-9422 in-state calls only 


1(800)203-3447 in-state calls only 


Delaware 


1(800)336-9500 in-state calls only 


1(800)282-8611 in-state calls only 


Florida 


1(800)963-5337 


1(800)342-2762 in-state calls only 


Georgia 


1(800)669-8387 


1(800)656-2298 


Guam 


1(888)875-9229 


1(671)475-1817 


Hawaii 


1(888)875-9229 


1(800)974-4000 in-state calls only 


Idaho 


1(800)247-4422 in-state calls only 


1(800)721-3272 in-state calls only 


Illinois 


1(800)548-9034 in-state calls only 


1(866)445-5364 in-state calls only 


Indiana 


1(800)452-4800 in-state calls only 


1(800)622-4461 in-state calls only 


Iowa 


1(800)351-4664 


1(800)351-4664 


Kansas 


1(800)860-5260 in-state calls only 


1(800)432-2484 in-state calls only 


Kentucky 


1(877)293-7447 


1(800)595-6053 


Louisiana 


1(800)259-5301 in-state calls only 


1(800)259-5300 in-state calls only 


Maine 


1(800)750-5353 in-state calls only 


1(800)300-5000 in-state calls only 


Maryland 


1(800)243-3425 in-state calls only 


1(800)492-6116 


Massachusetts 


1(800)882-2003 


1(617)521-7794 


Michigan 


1(800)803-7174 


1(877)999-6442 


Minnesota 


1(800)333-2433 


1(800)657-3602 in-state calls only 


Mississippi 


1(800)948-3090 


1(800)562-2957 in-state calls only 


Missouri 


1(800)390-3330 


1(800)726-7390 


Montana 


1(800)332-2272 in-state calls only 


1(800)332-6148 in-state calls only 


Nebraska 


1(800)234-7119 


1(800)234-7119 
79 



Section 6: For More Information 



State Name 


State Health Insurance Assistance 
Program 


State Insurance 
Department 


Nevada 


1(800)307-4444 


1(800)992-0900 in-state calls only 


New Hampshire 


1(800)852-3388 in-state calls only 


1(800)852-3416 


New Jersey 


1(800)792-8820 in-state calls only 


1(609)292-5360 


New Mexico 


1(800)432-2080 in-state calls only 


1(800)947-4722 in-state calls only 


New York 


1(800)333-4114 


1(800)342-3736 in-state calls only 


North Carolina 


1(800)443-9354 in-state calls only 


1(800)443-9354 in-state calls only 


North Dakota 


1(800)247-0560 


1(800)247-0560 


Northern Mariana 
Islands 


1(888)875-9229 


1(670)664-3017 


Ohio 


1(800)686-1578 


1(800)686-1578 


Oklahoma 


1(800)763-2828 in-state calls only 


1(800)522-0071 in-state calls only 


Oregon 


1(800)722-4134 in-state calls only 


1(800)722-4134 in-state calls only 


Pennsylvania 


1(800)783-7067 


1(877)881-6388 in-state calls only 


Puerto Rico 


1(877)725-4300 


1(787)722-8686 


Rhode Island 


1(401)222-2880 


1(401)222-2223 


South Carolina 


1(800)868-9095 


1(800)768-3467 in-state calls only 


South Dakota 


1(800)822-8804 in-state calls only 


1(605)773-3563 


Tennessee 


1(877)801-0044 


1(800)525-2816 


Texas 


1(800)252-9240 


1(800)252-3439 


Utah 


1(800)541-7735 in-state calls only 


1(866)350-6242 in-state calls only 


Vermont 


1(800)642-5119 in-state calls only 


1(800)631-7788 in-state calls only 


Virgin Islands 


1(340)772-7368 


1(340)774-7166 


Virginia 


1(800)552-3402 


1(800)552-7945 in-state calls only 


Washington 


1(800)397-4422 


1(800)397-4422 


Washington D.C. 


1(202)739-0668 


1(202)727-8000 


West Virginia 


1(877)987-4463 


1(800)642-9004 in-state calls only 


Wisconsin 


1(800)242-1060 


1(800)236-8517 in-state calls only 


Wyoming 


1(800)856-4398 


1(800)438-5768 in-state calls only 


80 







Section 7: 
Words To Know 




"I used this section to look up words I didn't know.' 

-Catherine 



81 



Section 7: Words To Know 



Assignment: In the Original Medicare Plan, this Durable Medical Equipment (DME): Medical 

means a doctor agrees to accept Medicare's fee as equipment that is ordered by a doctor for use in 

full payment. If you are in the Original Medicare the home. These items must be reusable, such as 

Plan, it can save you money if your doctor walkers, wheelchairs, or hospital beds. DME is 

accepts assignment. You still pay your share of paid for under Medicare Part B, and you pay 

the cost of the doctor's visit. 20% coinsurance in the Original Medicare Plan. 

Benefit Period: The way that Medicare measures Durable Medical Equipment Regional Carrier 

your use of hospital and skilled nursing facility (DMERC): A private company that contracts 

services. A benefit period begins the day you go with Medicare to pay bills for durable medical 

to a hospital or skilled nursing facility. The equipment. 

benefit period ends when you haven't received 

hospital or skilled nursing care for 60 days in a End-Stage Renal Disease (ESRD): Kidney 

row. If you go into the hospital after one benefit failure that is severe enough to require lifetime 

period has ended, a new benefit period begins. dialysis or a kidney transplant. 

You must pay the inpatient hospital deductible for 

each benefit period. There is no limit to the Excess Charges*: The difference between a 

number of benefit periods you can have. doctor's or other health care provider's actual 

charge (which may be limited by Medicare or the 

Coinsurance: The percent of the Medicare- state) and the Medicare-approved payment 

approved amount that you have to pay after you pay amount, 
the deductible for Part A and/or Part B. In the 

Original Medicare Plan, the coinsurance payment is Fiscal Intermediary: A private company that 

a percentage of the cost of the service (like 20%). has a contract with Medicare to pay Part A and 

some Part B bills. (Also called "Intermediary.") 
Copayment: In some Medicare health plans, the 

amount you pay for each medical service, like a Guaranteed Issue Rights (also called 

doctor visit. A copayment is usually a set amount "Medigap Protections"): Rights you have in 

you pay for a service. For example, this could be certain situations when insurance companies are 

$5 or $10 for a doctor visit. Copayments are also required by law to sell or offer you a Medigap 

used for some hospital outpatient services in the policy. In these situations, an insurance company 

Original Medicare Plan. can't deny you insurance coverage or place 

conditions on a policy, must cover you for all 

Deductible: The amount you must pay for health pre-existing conditions, and can't charge you 

care, before Medicare begins to pay, either for more for a policy because of past or present 

each benefit period for Part A, or each year for health problems. 
Part B. These amounts can change every year. 

* This definition in whole or in part was used with permission from Walter Feldesman, Esq., 
"Dictionary of Eldercare Terminology 2000." 

82 



Section 7: Words To Know 



Guaranteed Renewable: A right you have that 
requires your insurance company to allow you to 
automatically renew or continue your Medigap 
policy, unless you commit fraud or do not pay 
your premiums. 

Home Health Care: Skilled nursing care and 
certain other health care you get in your home for 
the treatment of an illness or injury. 

Hospice Care: A special way of caring for 
people who are terminally ill, and for their 
family. This care includes physical care and 
counseling. Hospice care is covered under 
Medicare Part A (Hospital Insurance). 

Lifetime Reserve Days: Sixty days that 
Medicare will pay for when you are in a hospital 
for more than 90 days. These 60 reserve days can 
be used only once during your lifetime. For each 
lifetime reserve day, Medicare pays all covered 
costs except for a daily coinsurance ($406 in 
2002). 

Limiting Charge: The highest amount of money 
you can be charged for a covered service by 
doctors and other health care providers who don't 
accept assignment. The limit is 15% over 
Medicare's approved amount. The limiting charge 
only applies to certain services and does not 
apply to supplies or equipment. 

Long-Term Care: A variety of services that help 
people with health or personal needs and 
activities of daily living over a long period of 
time. Long-term care can be provided at home, in 
the community, or in various types of facilities, 
including nursing homes and assisted living 
facilities. Most long-term care is "custodial care." 
Medicare does not pay for this type of care. 



Medicaid: A joint federal and state program that 
helps with medical costs for some people with 
low incomes and limited resources. Medicaid 
programs vary from state to state, but most health 
care costs are covered if you qualify for both 
Medicare and Medicaid. 

Medical Underwriting: The process that an 
insurance company uses to decide whether or not 
to take your application for insurance, whether or 
not to add a waiting period for pre-existing 
conditions (if your state law allows it), and how 
much to charge you for that insurance. 

Medically Necessary: Services or supplies that: 

• are proper and needed for the diagnosis or 
treatment of your medical condition; 

• are provided for the diagnosis, direct care, 
and treatment of your medical condition; 

• meet the standards of good medical 
practice in the medical community of your 
local area; and 

• are not mainly for the convenience of you 
or your doctor. 

Medicare + Choice Plan: A health plan, such as 
a Medicare managed care plan or Private Fee-for- 
Service plan, offered by a private company and 
approved by Medicare. An alternative to the 
Original Medicare Plan. 

Medicare- Approved Amount: The fee Medicare 
sets as reasonable for a covered medical service. 
This is the amount a doctor or supplier is paid by 
you and Medicare for a service or supply. It may 
be less than the actual amount charged by a 
doctor or supplier. The approved amount is 
sometimes called the "Approved Charge." 



83 



Section 7: Words To Know 



Medicare Carrier: A private company that has 
a contract with Medicare to pay Part B bills. 

Medicare Managed Care Plan: These are health 
care choices (like HMOs) in some areas of the 
country. In most plans, you can only go to 
doctors, specialists, or hospitals on the plan's list. 
Plans must cover all Medicare Part A and Part B 
health care. Some plans cover extras, like 
prescription drugs. Your costs may be lower than 
in the Original Medicare Plan. 

Medicare Private Fee-for-Service Plan: A 

private insurance plan that accepts people with 
Medicare. You may go to any Medicare-approved 
doctor or hospital that accepts the plan's 
payment. The insurance plan, rather than the 
Medicare program, decides how much it will pay 
and what you pay for the services you get. You 
may pay more for Medicare-covered benefits. 
You may have extra benefits the Original 
Medicare Plan does not cover. 

Medicare SELECT: A type of Medigap policy 
that may require you to use hospitals and, in 
some cases, doctors within its network to be 
eligible for full benefits. 

Medigap Policy: A Medicare supplement 
insurance policy sold by private insurance 
companies to fill "gaps" in Original Medicare 
Plan coverage. Except in Massachusetts, 
Minnesota, and Wisconsin, there are 10 
standardized plans labeled Plan A through Plan J. 
Medigap policies only work with the Original 
Medicare Plan. 



Open Enrollment Period (Medigap): A one- 
time-only six month period when you can buy 
any Medigap policy you want that is sold in your 
state. It starts when you sign up for Medicare 
Part B and you are age 65 or older. During this 
period, you cannot be denied coverage or charged 
more due to past or present health problems. 

Original Medicare Plan: A pay-per-visit health 
plan that lets you go to any doctor, hospital, or 
other health care provider who accepts Medicare. 
You must pay the deductible. Medicare pays its 
share of the Medicare-approved amount, and you 
pay your share (coinsurance). The Original 
Medicare Plan has two parts: Part A (Hospital 
Insurance) and Part B (Medical Insurance). 

Pre-Existing Condition (Medigap): A health 
problem you had before the date that a new 
insurance policy starts. 

Premium: The periodic payment to Medicare, an 
insurance company, or a health care plan for 

health care coverage. 

i 

Programs of All-inclusive Care for the Elderly 
(PACE): PACE combines medical, social, and 
long-term care services for frail people. PACE is 
available only in states that have chosen to offer 
it under Medicaid. To be eligible, you must: 

• Be 55 years old or older, 

• Live in the service area of the PACE program, 

• Be certified as eligible for nursing home care 
by the appropriate state agency, and 

• Be able to live safely in the community. 
The goal of PACE is to help people stay 
independent and living in their community as 
long as possible, while getting high quality care 
they need. 



84 



Section 7: Words To Know 



Skilled Nursing Care: A level of care that must 
be given or supervised by Registered Nurses. All 
of your needs are taken care of with this type of 
service. Examples of skilled care are: getting 
intravenous injections, tube feeding, oxygen to 
help you breathe, and changing sterile dressings 
on a wound. Any service that could be safely 
done by an average non-medical person (or one's 
self) without the supervision of a Registered 
Nurse is not considered skilled care. 

Skilled Nursing Facility: A nursing facility with 
the staff and equipment to give skilled nursing 
care and/or skilled rehabilitation services and 
other related health services. 

State Health Insurance Assistance Program: A 

state program that gets money from the Federal 
Government to give free health insurance 
counseling and assistance to people with 
Medicare. 

State Insurance Department: A state agency 
that regulates insurance and can provide 
information about Medigap policies and any 
insurance-related problem. 

State Medical Assistance Office: A state 
agency that is in charge of the State's Medicaid 
program and can provide information about 
programs to help pay medical bills for people 
with low incomes. Also provides help with 
prescription drug coverage. 



85 



NOTES 



"I bought my Medigap 
policy during my 
Medigap open enrollment 
period." 

-Ty 




86 



Section 8: Index 



Section 8 
Index 




This section is an alphabetical list of what is in this Guide. 



87 



mJ 



Section 8: Index 



Assignment 11, 12, 52, 82 

At-home Recovery 14, 22, 25 

Attained- Age-Rated Policies 34-35 

B 

Basic Benefits 13, 14,23 

Basic Drug Benefit 4, 25 

Benefit Period 69, 82 

Blood 12, 13, 23, 69, 70 



H 

High Deductible Option 14, 16 

Home and Community-Based 

Service/Waiver Programs (HCBS) 58, 62 

Home Health Care 5, 69, 70, 83 

Hospice Care 5, 69, 83 

Hospital Indemnity Insurance 58, 66 

I 
Issue-Age-Rated Policies 34, 35 



Coinsurance 12, 13, 23, 70, 82 

Consolidated Omnibus Budget Reconciliation 

Act of 1985 (COBRA) 58, 63, 64 

Copayment 12, 13, 23, 69, 70, 82 

Cost 15-17,34,35 

Creditable Coverage 18, 36, 37 

D 

Deductible 14, 16, 22-24, 82 

Disability 8,38-40 

Durable Medical 

Equipment 69, 70, 82 

Durable Medical 

Equipment Regional Carrier 68, 70, 82 

E 

Employee Coverage 58, 63 

Employer Group Health Plan ..7, 11, 19, 37, 44 
End- Stage Renal 

Disease (ESRD) 13, 18, 38-40, 82 

Excess Charges 12, 14, 22, 24, 82 

F 

Federally Qualified Health Centers 58, 62 

Fiscal Intermediary 68, 69, 82 

Foreign Travel Emergency 14, 16, 22, 24 

G 

General Enrollment Period (Part B) 7 

Group Health Coverage 7 

Guaranteed Issue Rights 36, 41, 82 

Guaranteed Renewable 10,49, 83 



Lifetime Reserve Days 69, 83 

Limiting Charge 53, 83 

Long-Term Care Insurance 58, 65 

M 

Medicaid 10, 11, 58, 60, 83 

Medical Underwriting 15, 16, 83 

Medically Necessary 5, 83 

Medicare + Choice 1,4, 10, 11,43-48,83 

Medicare Card 5 

Medicare Carrier 52, 68, 84 

Medicare Managed Care Plan 1, 4, 84 

Medicare Part A (Hospital Insurance) 4, 5, 69 

Medicare Part B (Medical 

Insurance) 1, 4-8, 70-72 

Medicare Personal Plan Finder ....27, 40, 73, 75 
Medicare Private 

Fee-for-Service Plan 1, 4, 11, 84 

Medicare Savings Programs 58, 59 

Medicare SELECT 11, 84 

Medicare Supplement Insurance.. (see Medigap) 
Medigap 

Cost 15-17, 34, 35 

Steps To Buying 20-31 

Under age 65 38-40 

What It Is 1, 10,84 

What's Covered 13 

What's Not Covered 13 

Why You Might Need It 11, 12 



88 



'U.S. Government Printing Office: 2002 - 743-181 



Section 8: Index 



M (continued) 

Medigap Benefits Chart 14 

For Massachusetts 73 

For Minnesota 74 

For Wisconsin 75 

Medigap Protections 41-47 

N 

No-Age-Rated Policies 34 

o 

Open Enrollment 

Period (Medigap) ....7, 18-20, 28, 36, 38-39, 84 

Original Medicare Plan 1,4, 10-12, 84 

Out-of-Pocket Costs 11 

P 
PACE (Programs of All-inclusive Care 

for the Elderly) 43-46, 58, 61, 84 

Part A (Hospital Insurance) 4, 5, 69 

Part B (Medical Insurance) 4-8, 18-20,70-72 

Pre-Existing Condition 16, 18, 36, 84 

Premium 5, 6, 10, 15, 34, 35, 84 

Prescription Drug Assistance 

Programs 58, 66 

Prescription Drugs 4, 13, 14, 16,22,25 

Preventive Care 14, 22, 25, 71-72 

Pricing Policies 15-17,34,35 

Private Contract 53, 54 

R 

Railroad Retirement Board 6, 7 

Reliability 27,56 

Retiree Coverage 58, 63 



Skilled Nursing Care 5, 14, 22, 24, 69, 85 

Skilled Nursing Facility 

Care 5, 14, 22, 24, 69, 85 

Social Security Administration 6-8 

Special Enrollment Period (Part B) 7, 8 

Specified Disease Insurance 58, 66 

Standardized Medigap Plans 10, 13, 14 

For Massachusetts 73 

For Minnesota 74 

For Wisconsin 75 

State Health Insurance Assistance 

Program 26, 27, 39, 42, 48, 56, 79, 80, 85 

State Insurance 

Department 27, 42, 48, 55, 56, 79, 80, 85 

State Medical Assistance 

Office 59-61, 85 

T 
TRICARE For Life/Military 

Retiree Benefits 37, 58, 65, 66 

u 

Union Coverage 7, 11, 19, 58, 63 

V 
Veterans' Benefits 58, 65 

w 

Waiting Period 36-38 

www.medicare.gov 4, 27, 40, 68-71, 73-75 






89 



U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard 

Baltimore, Maryland 21244-1850 

Official Business 

Penalty for Private Use, $300 

Publication No. CMS - 021 10 
Revised April 2002 






CMS LIBRARY 



3 flOIS DDD11D5T 1 



SfcRVICf* 




To get the 2002 Guide To Health Insurance For People With 
Medicare: Choosing a Medigap Policy on audiotape (English 
and Spanish), in Braille, Large Print (English), or Spanish, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

^Necesita usted una copia de esta guia en Espafiol? Tambien 
esta disponible en audiocassette. Llame gratis al 
1-800-MEDICARE (1-800-633-4227).